§ 3.48 p.m.
§ The Earl of Arran
My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.
§ Moved, That the House do now again resolve itself into Committee. —(The Earl of Arran.)
§ On Question, Motion agreed to.
§ House in Committee accordingly.
§ [The BARONESS SEROTA in the Chair.]
§ Clause 11 [Charges for dental appliances and treatment]:
§ The Principal Deputy Chairman of Committees (Baroness Serota)
In calling this amendment I should point out to the Committee that if it is agreed to I cannot call Amendment No. 31.
Baroness Gardner of Parkes moved Amendment No. 30:
Page 12, line 1, leave out subsection (7).
§ The noble Baroness said: I rise to move this amendment which has been tabled in my name. Although I was not aware that it was to be supported by the noble Lord, Lord Ennals, I notice that he has also put his name to the amendment. In the copy of the Marshalled List that I have I do not think that there are any other names added to mine, as yet. However, that is not an issue.
§ I should happily have brought the amendment forward entirely on my own, and indeed I submitted 1221 it that way. I have received a note from the noble Lord to say that he will join the Committee shortly as he is chairing another committee elsewhere. I understand that as soon as he sees on the monitor that the debate has started he will come to the Chamber. However, my speech will he quite independent and therefore would make no difference to whatever comments he has to make.
§ I speak as someone who has been in general dental practice in the health service for over 30 years. The suggestion to bring in a charge for a dental examination is a retrograde step. I appreciate the point made on Second Reading when the Minister said that the Government intended to raise more money from dentistry. I appreciate that there may be a need to do that, but there are other ways of doing so. At present there is a ceiling of £150 on any patient's payment. That represents 75 per cent. of the treatment cost up to that value; including the free examination. The Government could have made the ceiling higher. I am sure that such things can be worked out on a financial basis. If one paid 75 per cent. up to £200, that might well more than compensate for all free examinations. I do not know the arithmetic. I do not claim to have gone into it in detail. There are many ways of raising the same money from dentistry as would be raised through charging for a dental examination.
§ It is the principle of charging for a dental examination that I so strongly oppose. A dental examination is the preliminary to the diagnosis of any condition that a patient may have. Most importantly, it is the time when one picks up the presence of oral cancer at its early, pre-cancerous stage, or at an early and treatable stage. That is when people's lives are in one's hands. If such people are deterred from coming to the surgery they may allow the condition to continue and to reach the point where it is no longer treatable. People's whole lives are affected by small things which lead to some terrible illness that could have been discovered and dealt with.
§ During all my years of practice, all children's dental examinations have been free. They continue to be so. The importance of going to a dentist for an examination was to ensure that the children also attended. They were the ones with all the dental decay who needed to be seen not twice but three times a year. The Government will still pay for children to be seen three times a year, but children's dental decay is almost a thing of the past. The new problems in dentistry relate to older people who are on beta-blocking drugs for heart conditions or who are on other types of chemical treatment or therapy. They create new conditions in the oral mucosa. It is now the older patient who needs to be seen and checked twice a year, whereas for years we said to older patients, "Do not bother to come. At your age, your teeth do not decay. Come once a year". That has all changed. It is now the older patient who needs to come.
§ For the person who has no means, the examination will still he free. I have seen many elderly people who have been thrifty and saved a little money. They do not receive supplementary benefit and they have to meet all their costs. Whereas with a prescription they 1222 would receive free treatment, under this provision they will not. Every year some elderly people die of hypothermia even when they have money in the hank. They were brought up to be thrifty and careful, and they will not spend their last penny on heating the house. They will think twice about paying an amount which is now to be £3 but which I am sure, as happened with prescriptions, is just the start. Over the years that amount must obviously go up. How much more seriously will they then think, "I can do without going to the dentist. There is nothing wrong. Why do I need to go?" Often when things are wrong, they are without symptoms. They are pain- and trouble-free. People think that they can put off the visit for another year or so, but they do not know. The charge will he a deterrent.
§ I noticed that on Second Reading the Minister said that there were about 8 million dental examinations every year for patients who did not require treatment. That sounds as if we might generate £24 million if each person paid £3. However, there was no quantification of how many of those were receiving free treatment. I have no way of knowing whether one-quarter or three-quarters would be free. We cannot discuss what money will be produced by the examination charge.
§ It is important that one should want to go to the dentist. One may not want to go to the dentist; but there may be someone who loves and cares and is urging one to go for regular checks for preventive purposes, whether it he medical, for dentistry or the optician. I do not want any patient to be able to argue that he or she does not have £3 to spare that week and will put off the visit to the following week, month or year.
§ Baroness Gardner of Parkes
If the examination is free there is no excuse for not going. There is then no cash deterrent for the patient. The amendment is simple. It merely opposes the introduction of charging for a dental examination. I beg to move.
§ Lord Ennals
I support the noble Baroness. She made out a convincing case on Second Reading. I found it deeply moving. I am glad that she has proposed the amendment in Committee. It is a clear amendment. Many people will be deterred from having the examination. Even though the figure of £3, as she says, is not huge, people know that if they have their teeth examined that may well lead to a number of jobs being done and to considerable expense. I must make an admission to the Committee. Fearing that there was a possibility that the amendment moved by the noble Baroness might not get through, I have been to the dentist to have my free check. The dental examination showed that four teeth needed treatment. During the past few weeks I have clocked up almost £100-worth of treatment. If I had decided not to have my dental examination, I could have avoided that, but at a cost which will happen next year or the year after when I might have had to have teeth removed.
1223 It is clear where the British Dental Association stands on this matter. It believes that charging for check-ups will have a damaging and possibly disastrous effect on dental attendance. It says:The price of a check up may seem small. However, in charging for dental advice, alongside free health advice and health care that is offered elsewhere, the NHS would be making the clearest possible statement to patients and prospective patients that regular dental care is thought to be relatively unimportant. This may not be the intention but it is certainly the interpretation which many would put on the introduction of examination charges.The British Dental Association is strongly against the Government's proposals.
One must ask oneself why the Government believe that they know better than the dentists. The Committee would be wise to accept the view put forward by the noble Baroness. It would also give the lie to the suspicion which is deeply embedded in many people's minds that if this step were taken—the first time in 40 years when there would be a charge for an examination either by a general practitioner for some physical complaint, for eyes or teeth—it would be the first time people would have to pay for an examination. It is a dangerous step. I fear that if the Government take it, many people will feel that it is the first step down a route that could seriously undermine the National Health Service.
We have already worried about the costs of treatment but this is much more fundamental. As the noble Baroness and the noble Lord, Lord Colwyn, said on Second Reading, there is no doubt that very often the process of an examination discovers something which, if left untreated, could have a very serious effect. I believe that that is very important. It is not just a matter of teeth which may need to be repaired, it may well be a question of cancer, for example, as the noble Baroness mentioned.
Although there may be other matters in the Bill with which it can go along, I hope that the Committee as a whole will feel that this situation is not acceptable. I hope that the advice of the noble Baroness will be taken not only because of her position on those Benches but also in view of her professional skills. I hope that the Committee will accept the amendment which stands in her name and which she has proposed so movingly.
§ 4 p.m.
§ Lord Nugent of Guildford
I should like to speak in support of the Government, who seem to be a little short of support so far, especially after the very persuasive speech of my noble friend Lady Gardner. I correspond with the description that she gave. As I can testify, I still have a mouthful of teeth although some of them need repairs. As she said, it is perfectly true that it is older people who should go regularly for an examination. Mercifully, the children are beginning to show a wonderful record in the health of their teeth and they will continue to receive free treatment. I recognise the cogency of the case put by my noble friend with all her authority as a leading member of the dental profession.
I think that the noble Lord, Lord Ennals, spoke with great discrimination in a field which for him is full of broken glass because he has been responsible 1224 for presiding over the National Health Service in the past and indeed for administering the service which makes charges for dental and other purposes. He has picked out the point that the dental examination is a first step and therefore a very important one which has particular significance in this field.
However, I think it is right to ask the Committee to consider the broad context of the dental charges that we are now discussing. The fact is that all of us in this Chamber, and especially noble Lords who have been in the other place, are well aware that dental and optical charges have, in addition to charges to the taxpayer, been the normal method of raising revenue for the National Health Service ever since the very beginning. No doubt along with some other noble Lords I can recollect the very beginning of this question. In 1951 Mr. Gaitskell in his Budget speech announced the intention to introduce charges for optical and dental purposes, and very dramatic results flowed from it. However, he stuck to his decision and the Labour Government of the day stuck to it, and the fact is that ever since all governments have found it necessary, in order to meet the huge costs of the National Health Service which are ever rising and ever will, to make charges wherever they have thought appropriate.
Over the years those charges have been increased. I suppose that the first major increase was in 1968 and there were considerable increases again in 1976 and 1977, as the noble Lord, Lord Ennals, will remember. The present Government have made further increases since then.
This is a matter for the very expert judgment of the Secretary of State who is running the health service. He must try to raise the revenue that he needs for expansion of the services in a way which he has decided, with the assistance of his expert advisers, will not damage the service. It is a very delicate judgment but Secretaries of State of both complexions have been doing it for years and it is quite certain to continue.
We have to consider the matter in that context and judge whether or not it is reasonable for the Government to consider that these two sets of charges are the way to raise £100 million toward the extra £600 million which they wish to spend on primary health care. An extra £600 million over the next two years so that many desirable things can be done is a very valuable addition which everybody blesses and welcomes. The Government reckon that from these charges they can raise some £100 million toward that total. I must say that if that is their judgment, I feel that they have made out their case.
Let us turn to the particular charge of £3 a time which will be asked of a community whose incomes, except at the bottom end, are increasing annually. There will be exemptions which will exclude some 38 per cent. of the community—all those who are on any system of income support and those who come within the small margin above it. Something like 38 per cent. of the community will be excluded. The rest will be asked to pay £3. It is hard to believe that in our community today that sum will represent a serious deterrent.
1225 The noble Baroness most persuasively said that none of us welcomes a visit to the dentist; it is something that one puts off whenever one can and therefore to have to pay £3 might just be the straw that breaks the camel's back. However, I do not believe that it will. It is not really that much. It will raise the total level of charges for the dental services from the present figure of some 30 per cent. to 32 per cent. I do not believe that that will seriously deter people from going for an examination preparatory to having treatment. I hope therefore that the Committee will see this amendment in that context and despite the very persuasive pleading of my noble friend will not accept this amendment.
I am quite sure that all noble Lords on these Benches will wish to support the amendment of the noble Baroness, Lady Gardner. Speaking on their behalf I wish to say that I agree with every single word she said in a truly excellent and very clear speech in which she explained the purposes of the amendment. The noble Lord, Lord Nugent, described her speech as persuasive but he does not appear to he totally persuaded by it and I suspect that that it is because he does not fully understand it.
Never for a moment did the noble Baroness, Lady Gardner, say that she was opposed to charges. She referred to charges and the fact that people pay a very substantial proportion of the cost of their dental treatment. She was concerned about the charge for an examination which in point of fact may deter someone from going anywhere near the dentist at all. That would perhaps prevent later charges which might be very much heavier for treatment that the patient ought to have but which he will not have because he does not present himself at all.
The noble Baroness is absolutely right. As a general medical practitioner I know that patients do not like to go to see the dentist. For a variety of reasons, necessary or otherwise, they very much like to go to see the doctor but so far as dentists are concerned there is an inbuilt reluctance to go anywhere near them. If for one moment one once provides some kind of disincentive—and this charge does provide a very clear disincentive—then the plain and simple fact is that people just will not go to the dentist. I agree very strongly with the noble Baroness. She is concerned about the elderly. They are the people who will not go.
In an earlier speech at Second Reading the noble Baroness suggested that perhaps by their splendid work dentists had almost worked themselves out of employment because dental caries has now virtually disappeared. There are a variety of reasons for its disappearance and the work of dental practitioners is not the only one. The noble Lord, Lord Nugent, will know that some part of its disappearance is due to the fluoridation of water supplies. However, I do not wish to tread that stony ground at the moment. Dental caries has also disappeared because of an increasing understanding of dental hygiene and perhaps changes relating to sugar content and so on made in the diet of young children. The number of children who are not allowed sweets now is astonishing compared with the number of children 1226 who insisted on sweets almost every hour of almost every day in the past. That, too, has had an effect.
The noble Baroness pointed out that dentists have not gone out of employment because of the sensational reduction in dental caries. The new situation has meant that there are new dental problems with which dental surgeons have to cope regularly. One of those problems relates to dealing with people who have kept comparatively full mouths of teeth up to quite an advanced age. Elderly people who have kept all or most of their own teeth, although some of them may be loose, are now a common occurrence. They often have the beginnings of gum disease of one kind or another. Those people need attention in a way that they did not in the past as in the past so many of them had all their teeth extracted when they were 17 or 18. It is fortunate that we have passed those days and that people keep until later in life a full set of their own teeth. But that situation produces new and very difficult problems for my dental colleagues. They have to deal with those problems on a daily basis.
The noble Baroness also referred to the screening or examination of people's teeth at different ages which sometimes revealed other diseases. It is important to recognise that dental health is an integral part of health in general. There are many medical and indeed surgical conditions of which dental sepsis and abnormalities in the teeth can be a very important cause. It is often necessary for doctors to advise their own patients of whatever age group to see a dentist in order to have their teeth examined for a whole variety of reasons. One cannot separate the two. Health is health whether it is dental health or general health.
I ask the Committee to accept the objection of the noble Baroness to charges. Some of us on this side of the Committee object to charges of any kind. We should like to see a different method of financing the National Health Service. But that is not the argument of the noble Baroness at this stage. Her argument at this stage is a limited one. It is that the amount of a charge will be, as the noble Lord, Lord Nugent, pointed out, minuscule in comparison with the total amount that some people pay for their dental treatment. But by forfeiting that very small amount of money from the individual patient, the Government will forfeit a great deal more than the amount they would be paying for treatment if those people then needed to have treatment.
The main thrust of the argument of the noble Baroness is that the existence of this charge will undoubtedly prevent many people from going anywhere near a dentist when their health in general—not merely their dental health—makes it advisable that they should see a dentist for regular inspections. I hope that the Committee will support the amendment. I think it is immensely important.
§ Lord Colwyn
I also do not wish to prolong the debate too much. However, I wish to support my noble friend Lady Gardner of Parkes. Although I do not presently work within the National Health Service, I have over 20 years' experience of the practice of dentistry, and about 14 years' experience of dentistry in the National Health Service.
1227 One aspect of my work has always been very obvious. Here I agree with the noble Lord, Lord Winstanley. It is that most of us—and I include myself—do not enjoy having dental treatment. Only 20 per cent. of people visiting a dentist go for regular inspections whether they be at six, 12 or 18-monthly intervals. My profession has continually sought ways to encourage people to visit our surgeries. The fact that the initial examination was free was one of the most persuasive arguments of our long-fought campaign.
My noble friend the Minister will tell me that past increases in dental charges have not deterred people generally from seeking treatment, and that the number of courses of treatment has risen from just over 26 million in 1976 to 32 million last year. But the figures also show that, when charges went up in 1971–72 treatment per course went down by 7 per cent. When charges went up in 1977–78 treatment per course went down by 4 per cent. When charges went up in 1984–85 and 1986–87 treatments went down by 4 per cent. again.
Because of the considerable improvements in the nation's dental health and because of the increasing emphasis on the regular dental examination and preventive treatment, it must surely be a retrograde step to introduce a charge for routine examination. The charge could even be interpreted as a signal to the public that dental checkups are not an important screening activity. I shall not repeat the argument that the Minister will hear time and time again from the dentists at the moment and later on from the optometrists about the opportunity of early detection of more serious diseases. He may be quite correct when he tells us, as I am sure he will, that the incidence of detection of oral carcinomas is rare. But there are many other diseases which can show themselves in the mouth.
I have to admit that the long list of systemic diseases classified by the World Health Organisation, and listed in my brief from the British Dental Association, prompted me to refer back to some of my old dental textbooks, as I had quite forgotten how much information can be collected from a routine dental examination.
I hope that we shall not divide on this matter at this stage. My noble friend the Minister is a sensible, caring and influential member of the team from the DHSS. I am sure that he will be able to persuade his right honourable friend to change the Bill in a way that all sides of this Chamber are now suggesting.
§ 4.15 p.m.
§ Lord Trafford
We are discussing, or we have been discussing, two different things in all the speeches put forward. The first thing was the question of charges and their deterrent effect. That has been referred to in general terms. The proposition that has been put forward is a perfectly tenable one. It was that there should be no charges whatsoever on any of these things. That is a perfectly acceptable, understandable and tenable position. It is one I do not happen to share because I believe that there is no reason why those who cannot make some contribution should 1228 not have to make a contribution. That is the question of general charges.
But here we are talking about a specific charge for a specific type of treatment or check. One is tempted to say that there have been various types of charges for various types of checks. There have been rather complicated kinds of dental charging up to date. One is tempted to ask what is so special about this provision. It boils down to two things, as I understand it. The first argument is that vast numbers of people will suffer serious dental disasters if they are not prepared to pay a small sum of money—I gather it is a small sum of money—to have their teeth checked. The second argument is that a vast number of diseases will be missed. I know of hardly any group in the medical or the dental professions who could not put forward the same argument about every type of screening imaginable. Very little of that is proven.
It may be that at a later stage in this Bill someone else will raise this particular point. I can already see a Member of the Committee opposite smiling as if he has some intention of raising this point later. I shall be delighted to debate it; but I do not think that we need to do so at this point. I agree with my noble friend Lord Colwyn that it is uncommon for dental examination to result in the finding of significant or serious systemic disease. There are manifestations of disease in the mouth and we have heard of one or two of them. But they are also present in the skin. Perhaps we should all visit dermatologists. Diseases show their presence in a number of different ways. Perhaps we should all visit different types of practitioners so that one way or another these things can be found. There are simpler and cheaper tests which would show a higher return for cancer, if that is what is being looked for, than by a dental check.
For the past 37 years there have been charges of one kind or another for teeth and spectacles. I accept what my noble friend Lord Nugent of Guildford said as regards the introduction of charges by another party. I do not think it matters who introduced them or who was responsible for them. The fact is we have lived with them for a long time. We have recognised that they are necessary at the periphery and sometimes with the less significant things. No one is suggesting making a charge for some massive or major medical or dental catastrophe. We must remember that something like 40 per cent. of the population will he excluded from charges. We are already protecting a large number of people.
Why is it that we so often feel that we should have no responsibility for our health? Why should we think that £3 expended on our health—I think that was the sum given—is outrageous? But when we arrive at an airport we are charged £3 for some aviation fuel surcharge on a holiday. Similar charges are imposed for all kinds of things. We pay those charges with the greatest facility. But apparently it is something special to be asked to take some responsibility for looking after ourselves.
In one sense, with the greatest respect to the noble Baroness the amendment is based on special pleading. There are many other tests to which that argument could apply equally. I see that the noble Lord, Lord Ennals, is nodding yes. He is right. I 1229 accept that he makes the point that there are a number of screening tests to which the argument could apply.
§ Lord Trafford
Offhand, I do not think that I can answer that question. Perhaps there ought to be. However, I was making the point that there are many tests for which one might institute charges with a much better return. I believe that the noble Lord is a brave man. Not many politicians would come to either House and confess that they had recently had their mouths examined.
Be that as it may, it seems to me that it is a special situation if we say that a small charge, in an area where we have had charges for years, should not be made. We know that there will be considerable benefits to other parts of the dental and primary medical services as a result of the income that the proposed charges will generate. I have some sympathy with the amendment. However, I regard it as a piece of special pleading.
§ Baroness Masham of Ilton
We have a growing problem in that the number of AIDS patients doubles every 10 months. I am told that the first signs of the disease can be found in the mouth. Following a dental examination, the patient is counselled, and it is to be hoped, if the presence of the virus is confirmed, the patient will realise the need to prevent the spread of the disease. We must do everything we can to stop the spread of that terrible condition.
Perhaps I may ask the Minister whether pregnant women will be exempt from charges. They may have dental problems and need extra encouragement to go to the dentist. The reason people do not like going to a dentist is that it often hurts and many people are frightened. Therefore, dental examinations are different from other examinations. I support the amendment.
§ Viscount Hanworth
In my youth, many comparatively young people had no teeth at all. Whatever may be said about people being logical, the fact is that they are not. When one is young, one does not always think about the future. In my own case, I did not give much thought to my future financial position.
When it comes to making a concrete effort to get a dental examination, many people will put it off and end up not doing it. On the other hand, people who receive dental examinations may find they have problems which they did not know about. If they are then told that something needs to be done, they may be quite willing to pay for it. It is absolutely vital to have free preliminary investigations.
§ Baroness Blatch
The thing which has united everyone who has spoken both for and against the amendment is the importance of visits to the dentist. That must go unchallenged. The details which were given by my noble friends Lady Gardner and Lord Colwyn contained a list of a number of specific matters which may be detected by dentists. 1230 Therefore, the debate does not concern the importance of going to dentists but whether a charge of £3 will act as a deterrent.
I was struck by a statistic which my noble friend Lord Colwyn gave. He said that only about 20 per cent. of people go to a dentist regularly. We need to ask why that is so. I suspect that it has a great deal to do with the matters which the noble Baroness, Lady Masham, outlined. We do not like to go to dentists because of what happens to us when we get there. I am not sure whether levying a charge of £3 per visit will make it easier or more painful to go to a dentist. The uppermost thought in the minds of most people is the awful feeling of sitting in a dentist's chair with the white coats, the mirrors, the sound of the drills, and so on.
There are people who feel very strongly that levying any kind of charge for an initial check-up will act as a deterrent. However, we do not know that that is the case. At the end of the day, it comes down to a balance between two positions. The first requires the levying of a modest charge and doing what we can to encourage people to go to the dentist. We should overcome the fears that we all have and, in addition, apply the income to needier parts of the health service.
The second position would continue to give free initial check-ups to everyone, irrespective of means. I ask the noble Lord, Lord Ennals, whether a charge of £3 would have deterred him from spending £100 on his course of treatment. I am not sure.
Should we continue free check-ups across the board, irrespective of means, and forgo the income from a charge? That is the nub of our discussions today. The question is whether the recycling of money within the health service is worth trying. I cannot believe that a charge of £3 for an initial visit will make much of a dent in the numbers of people going for check-ups.
I also believe we need to make continued efforts to convince people how important visits to the dentist are. The shift in statistics which was mentioned by my noble friend Lady Gardner highlighted the need for examinations for older people. We as parents always have it in the back of our minds that it is essential for our children to go to the dentist and they are protected in the Bill. However, the shift in need for the elderly requires further publicity.
§ 4.30 p.m.
§ Lord Skelmersdale
I recognise (who would not after our short debate?) that the issue of charging for dental and optical services is the most controversial issue in the Bill. Perhaps I may add a reason for that which has not been adduced by the proposers and supporters of the amendment. When people have grown up over two generations with a free service, it comes hard to them to find that those services must be paid for. However, this is a transitory matter. Charges were introduced in 1951 and at other times in the past. In those cases there was a short period of decline of take-up and then the situation righted itself.
As the noble Baroness, Lady Masham, has said, some medical conditions can be spotted at the time of 1231 dental or optical inspection. Whether they are spotted depends on only two things. One is the ability of the clinician to detect them. That is not always the case but it does happen. The other is the likelihood that the individual will go to the dentist or optician. It is what my right honourable friend the Minister for Health calls a most opportunistic method of screening. It depends on getting an individual into the chair at the right moment and then diagnosing a medical condition if it exists.
Clearly the Committee recognises that dentists can and do spot certain conditions—for example, oral cancer or AIDS, as was mentioned by the noble Baroness, Lady Masham. However, my noble friend Lady Gardner recognised that oral conditions spotted by dentists are extremely rare. I am sure that she will remember referring at Second Reading to a particular case and then saying (at col. 1060 of Hansard for 26th May) that:Our practice has picked up six similar conditions in 30 years".My own advice was that it would normally be expected that such conditions could be picked up twice during a dentist's normal working life. That fits in with what the noble Baroness said.
Better identification of a wide range of conditions which might have oral symptoms, such as diabetes, cancer or AIDS, is something that we want to develop across the primary care services generally. We intend to pursue that through our discussions on the White Paper.
As I indicated in our debate on Second Reading, we need to look at the clause in context. We propose to invest substantial extra resources in the primary care services. Spending on those services has increased in real terms by 43 per cent. between 1978–79 and 1987–88, compared with an increase of 14 per cent. in real terms in overall public expenditure over the same period. Further substantial real terms increases are expected in the years ahead. The White Paper recognised that that extra money has to come from somewhere. In the absence of any concrete suggestions from the consultees, one of the means we have chosen is to ask patients who can afford it to pay towards the cost of their dental examination. We shall do that by treating the examination in the same way as other treatments so that it will attract a charge of three-quarters of the fee.
Currently the department pays dentists a fee of £3.90 for each examination, so that if we were introducing the charge today patients would pay three-quarters of £3.90, which is £2.92. When the charge is introduced the fee will be somewhat higher because fees are due for review this October anyway—I cannot yet say how much they will—be and the charge will be three-quarters of the new fee.
In our debate on Thursday last the noble Lord, Lord Ennals, used the analogy of a Yorkie chocolate bar costing 22 pence. My noble friend Lady Blatch is quite right: the fundamental question is whether charges for dental inspection—very modest charges at that—of, as I have said, about £3 in current terms, which most patients will have to pay no more than once a year, will deter people from going to the 1232 dentist. That £3 is equivalent to 13.63 recurring Yorkies a year—in other words about 0.26 which is fractionally over a quarter of a Yorkie bar a week. Are we seriously being asked to believe that that amount will be a deterrent?
Ah, but—I am about to anticipate the noble Lord, I think. If I am not I shall gladly give way. Ah, say the supporters of this amendment, it is not the amount but the principle of the payment which is at issue.
§ Lord Stoddart of Swindon
Of course I am against the principle. I am obliged to the noble Lord for giving way. He and other noble Lords have mentioned the figure of £3. We accept that that is what the fee will be when it is introduced. In 1979 the prescription charge was 20 pence. It is now—or was the last time I paid for a prescription £2.40. Are we talking about a mere £3 or is it likely that the dental inspection charge will increase by the same kind of percentage as the prescription charge?
§ Lord Skelmersdale
If I may, I shall return to that point in just a second. Obviously it is a very real and very valid point. I would say for the moment that we are not comparing charges for dental inspections with prescription charges. We should be comparing them with the charges for dental treatment, which are rather different. I have told the Committee that the new charge for the inspection will he made on exactly the same basis as the existing charges for treatment.
It is the principle of the payment which worries many Members of the Committee. My noble friend Lord Nugent reminded us that the principle was dented long since, when, in 1951 under a Labour Government, charges in the primary health care field were brought in for dentures. Even if the principle had not been dented we have incontrovertible evidence that today, in 1988, increased charges for dental treatment do not lead to reductions in demand or have any long-term effect on the upward growth in demand over the years. In answer to my noble friend Lord Colwyn, I would repeat the point that I made a few moments ago that there is very often a temporary dip in demand when large increases have been made but the long-term trend is for a continuing upward growth in demand.
I would refer Members of the Committee to the Official Report of the proceedings for last Thursday, 14th July. In col. 1013 there is a table setting out the growth in the numbers of courses of treatment and in the average charge for each year since 1975. Even when there were increases of 35 per cent., as there were between 1975 and 1976, the number of treatments rose.
The noble Lord, Lord Winstanley, mentioned pensioners. I can illustrate my point even more dramatically in relation to them. The noble Lord is quite right: their demand for dental care is rising faster than for any other age group. Over the period 1979 to 1986–87, the number of courses of treatment for the over 64 age group rose from 1.2 million to 2.3 million in England and Wales, an increase of 92 per cent. as against an increase for all age groups of 19 per cent. In no fewer than 85 per cent. of cases pensioners pay the full charge. Clearly, pensioners 1233 are seeking dental care more and more and cheerfully paying the charge because they know what good value it is.
When we look at the nation's dental health record in recent years and the contribution made by the general dental service, we see a major success story. There have been dramatic improvements in dental health in all age groups, particularly among children. In 1973 in England and Wales 29 per cent. of five year-olds were free of dental decay. By 1983 that figure had risen to 52 per cent. The proportion of adults with no natural teeth fell from 37 per cent. in 1968 to 22 per cent. in 1985. Attendance at the dentist continues to rise steadily. The percentage of dentate adults attending the dentist regularly—and again I must correct my noble friend Lord Colwyn on this point- has increased from 40 per cent. in 1968 to 50 per cent. in 1985. Scotland has seen improvements on a similar scale.
The figure of 20 per cent. mentioned by my noble friend is the number of courses where there is an examination only. That is not the same as those who attend regularly, a number of whom require treatment. In 1985 the percentage of adults who had regular check-ups was 50 per cent.—still not enough, I accept, but a more encouraging figure than that quoted by my noble friend.
Against the background of these major successes we consider it reasonable to increase the proportion of the cost of the general dental service contributed by patients and thereby help to pay for the developments we all want to see in the primary care services. I shall not repeat here all the developments we propose—they are set out in full in the White Paper.
However, I should like to mention briefly four of those developments. The first is fluoridation. More money is already being provided for new fluoridation schemes to meet a higher percentage of the total costs and to extend payments for the major cost of replacement of outdated plant and equipment. A total of over £1 million is being provided in 1988–89, which is £400,000 above the previously planned total. The additional sums will be further increased in subsequent years.
Noble Lords, very correctly and naturally, are interested in health education. We are funding an initiative in the West Midlands to investigate means of improving the marketing of dental care and increasing the number of people who seek regular dental care. We are also funding initiatives of the Health Education Authority in the North Western region to improve dental awareness and encourage people to seek dental care.
There will be financial assistance towards the cost of establishing and equipping practices in underdentisted areas, which is clearly a good thing to do. We hope to start that scheme from the beginning of next year. Additional resources will be provided to expand the number of places in the vocational training scheme. We want to do many things, which is why we judge that the time is right to get a very small proportion of the money needed from consumers themselves.
1234 Members of the Committee have asked about prevention. The dental examination charge is not in any way contrary to the philosophy of prevention as set out in the White Paper Promoting Better Health. It will still pay people to visit the dentist regularly. Moreover, the charge will help to release resources for positive measures to encourage the prevention of dental disease. These will include more fluoridation, improved and more widespread vocational and postgraduate training for dentists and a new programme to promote dental awareness among young people. It will also help to finance preventive measures in other primary care services. Even with the new charges, many consumers will pay the same amount of money for inspections as they did under the old pre-April system. For some, combined charges will be lower than last year. I cannot see how the charges can possibly deter people from going to the dentist. The existing groups of exempt people, including pregnant women, referred to by the noble Baroness, Lady Masham of Ilton, will of course continue to be exempt.
My noble friend Lady Gardner of Parkes very properly suggested another way to raise the money. She offered an amendment in lieu of the proposals in the Bill. I observe that my noble friend cast some doubt on the amount of money to be raised by the dental examination charge. Despite the many exemptions, we estimate that it will bring in some £40 million in England and £49 million in Great Britain. This will help pay for the £600 million additional expenditure in real terms that we plan for the family practitioner services. The maximum charge of £150 is paid by only about 100,000 patients. It would not be possible to raise anything like the £40 million a year in a full year that we expect from the examination charge. Without the examination charge, a back-ofthe-envelope calculation tells me that we should have to increase the proportional charge to 90 per cent. of the cost of treatments from the present 75 per cent. I am sure that the Committee would not want us to go down that route.
The new charges referred to in Clause 11 are identical in scope to charges for treatment; in other words, children, people on low incomes and the other well-known groups will also be exempt from the new charges. Lastly, on the basis of current treatment fees, many of those already paying for treatment as a result of the new charging mechanism introduced in April this year will, even with the new charges, pay about the same amount of money for inspections as they did without the new charges under the old pre-April system. For some people the combined charge will be below what it was last year, again on the basis of current fees.
With the best will in the world, I cannot see how the charges can possibly deter people from going to the dentist, where the medical problems will be picked up in exactly the same way as now. If my noble friend presses the amendment to a vote, I must therefore advise the Committee to reject it.
Can the Minister explain the apparent conflict in the argument that he has addressed to the Committee? He said, among other things, that the money raised by the charge can go 1235 towards other preventive schemes. He referred to those, and told us that they are in the White Paper. The Minister will know that his department is encouraging screening programmes to be carried out for a variety of different conditions. To make sure that those screening programmes are carried out, it is proposed to pay medical practitioners to carry out the screening. To make sure that dental screening continues, it is now proposed to make the patients pay for the screening. As a parallel, that seems to me to be just about perpendicular.
§ 4.45 p.m.
§ Lord Skelmersdale
I am not sure that one can have a perpendicular parallel. I did not refer to the point because I thought that my noble friend Lord Trafford had dealt with it very well when he spoke about the cost effectiveness of screening. With the very small number to which I referred, it simply is not sensible to set up a detailed screening system comparable, for example, with breast cancer or cervical smear screening. I do not regard this opportunistic form of screening as conventional screening. I referred to it earlier as better identification of a wide range of conditions that might have oral symptoms. This is something that we want to develop across the primary care services generally and intend to pursue through our discussions on the White Paper. I think that my noble friend Lord Trafford and I between us have answered the point.
§ Lord Ennals
In his original intervention and in his supplementary intervention the Minister appeared to fall into the same trap as his noble friends Lord Nugent of Guildford and Lord Trafford. They spoke as if charges for screening or examination were just the same as charges for treatment. At this stage we are not discussing charges for treatment, although the Minister did so in his response.
If one goes back to 1951, there was no introduction of charges for examination. There has been no charge for examination in the National Health Service in the 40 years of its existence. Sight testing, dentistry, cervical screening, breast cancer screening and pregnancy testing are all carried out free. Surely the logic of what the Minister and his two noble friends are saying is that, if it is all right to get some of the money that the health service desperately needs from preventive treatment because the Chancellor will not produce it, then why not do the same in regard to breast screening, cervical cancer and a visit to the general practitioner? The initial visit to the GP is to find out what is wrong. The next step is the treatment of what is wrong. The Minister cannot deny that, if the Bill goes through in this form without the amendment now proposed, it will be the first time in 40 years that charges for health examination have been introduced. I plead with Members of the Committee not to go down that route. Once we start down that route, where will it stop?
§ Lord Skelmersdale
The noble Lord is trying to compare two quite separate things. There have never been charges for screening, and we are not proposing charges for screening now. As I said in answer to the 1236 noble Lord, Lord Winstanley, the dental inspection and indeed the optical test are not conventional forms of screening. This is the most opportunistic form of screening that could be invented.
§ Lord Hunter of Newington
The Minister said on Second Reading that after a careful examination of priorities the Government had concluded that it was reasonable to find some of the savings from within the general ophthalmic and general dental services. Can the Minister say whether the Government think that the risks in regard to these two things are broadly similar? If one is to assume that savings have to be made somewhere, it would be helpful to have an indication of the Government's view about the relative dangers of doing either of these things.
§ Lord Skelmersdale
We are talking not about savings but about the expected extra expenditure of around £600 million on the primary health care services over the next three years, as I have now said several times. The money has to come from somewhere. The Government have concluded that the time is now right for a small proportion of it to come from charging for dental inspections.
§ Lord Stoddart of Swindon
Perhaps the Minister can give us some clarification, because he has confused me and, I think, other Members of the Committee. He said that a dental examination was not a screening. If it is not a screening, what on earth is it? Are we now being told by the Government that before a person goes to the dentist he or she has to have toothache, by which time it is probably too late to save the tooth? That is what the Minister appears to be saying.
§ Lord Skelmersdale
As has been explained, screening is where one has a system of call and recall aimed at 100 per cent. of a target population. I think the noble Lord, Lord Ennals, would agree with that. Under the existing or proposed system, in no way could that definition be given to the activities of dentists carrying out dental inspections.
§ Baroness Gardner of Parkes
I understand that when my noble friend Lord Colwyn moved an amendment earlier in Committee on this Bill, the principle was accepted that school children needed dental screening and that that meant an examination. Therefore, it has already been accepted by Members of the Committee that a dental examination is a form of screening. I certainly so consider it. I was quite disturbed to hear the view of my noble friend Lord Trafford that there was no reason in the world why screening should continue to be free. That was the message that I received from his speech. It is worrying if my noble friend is suggesting that this is only the tip of the iceberg and that we may find a charge for all other screenings. The point is made even more importantly. If this is the first charge for any form of screening or examination in the health service then this will decide the future of all other types of screening that we have to consider.
I accept the point the Minister has made that money has to come from somewhere. I support the 1237 view of trying to find extra ways of bringing money into the health service. I am still convinced that there would be other ways of raising the same amount of money from patients as there would be through this charge, and I should not be opposed to that. The patient who is paying the £150 ceiling and perhaps receiving treatment worth £1,000 or £2,000 is getting a real bargain. I believe that there is room for changes within the costing. However, I cannot accept that this is the way to start. Before people walk through the door, they know that they have a charge to meet. It is not a matter of what the charge is because it has varied over the years.
I do not believe the point made by my noble friend Lord Nugent, or perhaps by my noble friend Lord Trafford, that there had been dental charges since they were first introduced in 1951 to be correct. Yes, there have been dental charges for treatment, but never dental charges for examination. That is the difference with this amendment. I regret that I am not satisfied with the answers. I have to seek the opinion of the House.
§ 4.53 p.m.
§ On Question, Whether the said amendment (No. 30) shall be agreed to?
§ Their Lordships divided: Contents, 118; Not-Contents, 97.1238
|DIVISION NO. 1|
|Addington, L.||Galpern, L.|
|Adrian, L.||Gardner of Parkes, B.[Teller]|
|Airedale, L.||Glenamara, L.|
|Allen of Abbeydale, L.||Graham of Edmonton, L. [Teller.]|
|Auckland, L.||Gregson, L.|
|Aylestone, L.||Halshury, E.|
|Banks, L.||Hampton, L.|
|Birk, B.||Hanworth, V.|
|Blease, L.||Harris of Greenwich, L.|
|Bonham-Carte, L.||Hart of South Lanark, B.|
|Bottomley, L.||Hatch of Lusy, L.|
|Brightman, L.||Headfort, M.|
|Brooks of Tremorfa, L.||Henderson of Brompton, L.|
|Brougham and Vaux, L.||Hughes, L.|
|Bruce of Donington, L.||Hunt, L.|
|Carmichael of Kelvingrove, L.||Hunter of Newington, L.|
|Cledwyn of Penrhos, L.||Irving of Dartford, L.|
|Cocks of Hartcliffe, L.||Jacques, L.|
|Colwyn, L.||John-Mackie, L.|
|Cornwallis, L.||Kennet, L.|
|Cudlipp, L.||Kilbracken, L.|
|Cullen of Ashbourne, L.||Lawrence, L.|
|Darcy (de Knayth), B.||Listowel, E.|
|Davies of Penrhys, L.||Lockwood, B.|
|Dean of Beswick, L.||Longford, E.|
|Donaldson of Kingsbridge, L.||Lovell-Davies, L.|
|Dormand of Easington, L.||Lucas of Chilworth, L.|
|Ellenborough, L.||McIntosh of Haringey, L.|
|Elliot of Harwood, B.||McNair, L.|
|Elwyn-Jones, L.||Manton, L.|
|Ennals, L.||Masham of Ilton, B.|
|Ewart-Biggs, B.||Mason of Barnsley, L.|
|Faithfull, B.||Mayhew, L.|
|Falkender, B.||Merrivale, L.|
|Falkland, V.||Middleton, L.|
|Fisher of Rednal, B.||Molloy, L.|
|Foot, L.||Morton of Shuna, L.|
|Fortescue, E.||Mulley, L.|
|Gallacher, L.||Nicol, B.|
|O'Neill of the Maine, L.||Stallard, L.|
|Oram, L.||Stedman, B.|
|Paget of Northampton, L.||Stoddart of Swindon, L.|
|Parry, L.||Taylor of Blackburn, L.|
|Peston, L.||Taylor of Gryfe, L.|
|Ponsonby of Shulbrede, L.||Taylor of Mansfield, L.|
|Prys-Davies, L.||Thurlow, L.|
|Raglan, L.||Tordoff, L.|
|Rathcreedan, L.||Turner of Camden, B.|
|Rea, L.||Underhill, L.|
|Richardson, L.||Wallace of Coslany, L.|
|Ritchie of Dundee, L.||Wells-Pestell L.|
|Rochester, L.||Whaddon, L.|
|Sainsbury, L.||White, B.|
|Saltoun of Abernethy, Ly.||Williams of Elvel, L.|
|Serota, B.||Willis, L.|
|Shackleton, L.||Winstanley, L.|
|Simon, V.||Wise, L.|
|Aldington, L.||Kimball, L.|
|Allerton, L.||Kimberley, E.|
|Alport, L.||Kitchener, E.|
|Arran, E.||Layton, L.|
|Balfour, E.||Lindsey and Abingdon, E.|
|Bauer, L.||Long, V.|
|Beaverbrook, L.||McFadzean, L.|
|Belhaven and Stenton, L.||Mackay of Clashfern, L.|
|Beloff, L.||Marley, L.|
|Belstead, L.||Monk Bretton, L.|
|Bessborough, E.||Monson, L.|
|Blatch, B.||Montagu of Beaulieu, L.|
|Borthwick, L.||Mountgarret, V.|
|Brookeborough, V.||Mowbray and Stourton, L.|
|Broxbourne, L.||Munster, E.|
|Bruce-Gardyne, L.||Nelson, E.|
|Burton, L.||Northesk, E.|
|Caithness, E.||Nugent of Guildford, L.|
|Cameron of Lochbroom, L.||Orkney, E.|
|Campbell of Croy, L.||Orr-Ewing, L.|
|Carnegy of Lour, B.||Oxfuird, V.|
|Carnock, L.||Pender, L.|
|Cathcart, E.||Peyton of Yeovil, L.|
|Chelwood, L.||Polwarth, L.|
|Colnbrook, L.||Poritt, L.|
|Constantine of Stanmore, L.||Rankeillour, L.|
|Cox, B.||Reigate, L.|
|Davidson, V. [Teller.]||Renwick, L.|
|De Freyne, L.||Rippon of Hexham, L.|
|Denham, L. [Teller.]||Rodney, L.|
|Eccles, V.||St. Aldwyn, E.|
|Elliott of Morpeth, L.||St. Davids, V.|
|Erroll of Hale, L.||Sanderson of Bowden, L.|
|Fanshawe of Richmond, L.||Savile, L.|
|Ferrers, E.||Selborne, E.|
|Gisborough, L.||Skelmersdale, L.|
|Glenarthur, L.||Strange, B.|
|Grimston of Westbury, L.||Strathcarron, L.|
|Hailsham of Saint Marylebone, L.||Strathcona and Mount Royal, L.|
|Hardinge of Penshurst, L.||Strathspey, L.|
|Harvington, L.||Swinfen, L.|
|Havers, L.||Swinton, E.|
|Hesketh, L.||Terrington, L.|
|Hives, L.||Thomas of Gwydir, L.|
|Home of the Hirsel, L.||Trafford, L.|
|Hood, V.||Trumpington, B.|
|Hooper, B.||Windlesham, L.|
|Johnston of Rockport, L.||Wyatt of Weeford, L.|
§ Resolved in the affirmative, and amendment agreed to accordingly.
§ 5.1 p.m.1239
§ Baroness Gardner of Parkes
I understood the Deputy Chairman to say that Amendment No. 31 could not be moved if Amendment No. 30 was agreed to.
§ The Deputy Chairman of Committees
I beg the Committee's pardon. That is quite right. I was so surprised at the last result.
Baroness Gardner of Parkes moved Amendment No. 32:
Page 12, line 7, at end insert—
("(9) Section 81(b) of the National Health Service Act 1977 and section 73(b) of the National Health Service (Scotland) Act 1978 shall cease to have effect.").
§ The noble Baroness said: I do not wish to take long on this amendment and I certainly do not intend to divide the Committee on it. The amendment would bring about a change in doing away with a form which is hardly used now. If a patient says that instead of a denture he would like a bridge, the dentist has to fill up a very complicated form and send it in. The dentist is still not allowed to agree a fee with the patient and still has a fee sent back by the National Health Service.
§ For that reason it is such a frustrating and complicated procedure that hardly anyone uses it. I believe that only 95 cases used the scheme out of all the millions of cases last year. I understand from the Minister that this may be one of the subjects to be discussed with the general dental services at a later stage, so this is really a probing amendment at this stage. I beg to move.
§ Lord Skelmersdale
I fully understand my noble friend's intention in moving this amendment. It is to remove from the National Health Service Act 1977 and its Scottish equivalent a regulation-making power under which a long-standing provision has been made enabling a dentist to supply under the National Health Service, at the patient's request, a denture, bridge, crown, gold filling or inlay of a type more expensive than the dentist considers clinically necessary, the patient paying the excess cost in full. The main advantage of the scheme is that it enables patients to top up out of their own pockets what the NHS is prepared to provide by paying the extra cost of an item which goes beyond what is needed for the strict purposes of dental fitness.
I take the point that the level of demand for this extra service has fallen to a low level over the years. It is clear therefore that the time has come for a review. I believe that I can give my noble friend the assurance she is seeking in putting down this amendment that we shall he discussing its future with representatives of the profession probably in the context of the negotiations on the new dental contract when these begin formally, which I hope will be later in the year.
I should perhaps clarify one point, however. This is that whatever is decided for the scheme, whether it is to extend its scope or to reduce it or to abolish it altogether, or revise it in the context of the new contractual arrangements which will emerge from the negotiations, we can proceed by way of amendment to the regulations. In other words, an amendment to this Bill would not be required.
§ Baroness Gardner of Parkes
I thank the Minister for his reply and beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Clause 11, as amended, agreed to.
§ Clause 12 [The Dental Estimates Board and the Scottish Dental Estimates Board—change of name and extension of functions]:
Lord Skelmersdale moved Amendment No. 33:
Page 13, line 3, leave out from first ("to") to end of line 6 and insert ("carry on any such additional activity relating the provision of general dental services as may be prescribed and, without prejudice to the generality of this subsection, to conduct or commission surveys or other research relating to the provision of such services.").
§ The noble Lord said: This is a technical amendment. In Committee in another place my right honourable friend was pressed on whether the current wording in subsection (3) (b) (1C) was sufficiently wide to allow sensible research activity on the general dental services to be undertaken by the boards. This amendment clarifies the position and removes any unintended inflexibility. I beg to move.
§ On Question, amendment agreed to.
§ Clause 12, as amended, agreed to.
§ Clause 13 [General ophthalmic services and optical appliances]:
Lord Lucas of Chilworth moved Amendment No. 34:
Page 13, line 18, leave out subsection (1).
§ The noble Lord said: With this amendment I speak also to Amendments Nos. 45 and 46 in the name of my noble friend Lord Mottistone and the noble Lord, Lord Ennals. I find myself in some little difficulty since the Committee has agreed that the principle for charging for examinations or screening for dental health shall be free. I am concerned with the eyes.
§ I was proposing to deliver a fairly long argument as to why the fees for eyesight testing or eye screening should not be applied, but it seems to me that the Committee would sooner accept the argument which is precisely the same as that put forward by my noble friend Lady Gardner of Parkes. She spoke about the 40 years. She talked about the costs, whether it is £3 for dental inspection or £10 for an optical inspection. Here we already have charges building up. We have dealt with all that.
§ About 12 million eye examinations are carried out annually, the bulk of them through ophthalmic opticians and ophthalmic medical practitioners. About one-twelfth of those examinations and screenings show a health defect, an abnormality or disease. It might be sufficient to alert the Committee to the fact that we are talking of a similar problem. One can overcome this in some ways by the GP— until such time as a consultation fee is imposed for him—being able to refer patients directly to the eye hospital so momentarily avoiding a charge. Again the argument is the same concerning the age bracket, in so far as eye disease is more prevalent as one gets older, starting about 45 or 50 years of age.1241
§ We are an ageing society. We cannot get away from that, so we shall have more problems with eye disease among the population in 10 or 15 years' time. I do not propose to argue about whether the charge which the Government estimate they will receive of some £80 million against the £10, or just short of £10, which the Government pay the ophthalmic profession is right or not. What I do know, however, is that the cost of maintaining a blind person is about £3,500 a year. This seems to me to be a very odd equation. That might raise £80 million. I have to ask my noble friend how much he estimates in 20 years' time we shall spend on the hospital service for the maintenance of blind or partially blind people and the attendant social costs. I believe that the cost is vastly in excess of £80 million. Therefore we are deferring a payment to another day and that does not seem to be a good practical sense.
§ Essentially that is the argument. It is a fact that in 1982 a small survey was carried out at the surgical unit at the University of Southampton. It was found that 63½per cent. of the patients in the survey were diagnosed as a result of their seeking advice for ocular symptoms. Those patients went to the opthalmic optician and said "Please test my eyes. I am not seeing as well"; or "The television is fuzzy". Disease was determined by that examination.
§ I believe that whatever the fee, people will put off the evil hour to spend it. When they finally do so it will be too late. I am not an optician or a doctor but I am told, that, for example, wide-angled glaucoma does not have a tangible feel about it. It is almost symptomless until one day it is there and it is too late to do anything about it. I shall return to that matter in respect of another amendment concerning drivers. I believe that that symptom could slip through the net and we shall be in trouble on a number of fronts.
§ That is the basis of the argument for the continuance of free examinations. We make a weekly payment to the National Health Service so it is not actually free, but I believe that the Committee knows what I mean by the word "free". I believe that we should continue the present system as regards eye testing, as the Committee has agreed in respect of dentistry, and that we should continue to make available a free screening, examination or inspection. I beg to move.
§ The Deputy Chairman of Committees
I must advise the Committee that if the amendment is agreed to I cannot call Amendments Nos. 35 to 44 inclusive.
§ Lord Ennals
I hope that that will be the case because it will save the Committee a good deal of time. I should like to support the noble Lord, Lord Lucas, who made the case for the amendment extremely well. In his last few remarks he said that a condition of the eye may not be apparent. I understand that there are a number of sight-threatening conditions which are symptomless, particularly in the early stages. They include glaucoma, diabetic retinopathy and muscular degeneration.
In the early stages those conditions can be detected only by thorough sight-testing. There is no pain and no one will have a reason to visit an optician. The 1242 condition will be discovered only if they have an examination. In 1980 glaucoma caused 2,000 people to lose their sight. Opticians identified two-thirds of sufferers as a result of the tests. I believe that 70 per cent. of diabetic blindness can be prevented if eyes are checked regularly.
I believe that the case for this amendment is even stronger than that for the previous amendment. There are a wider range of eye conditions which can be detected only by a proper professional examination. They can all lead either to great pain or total blindness in one eye or both. As a consequence people who have not visited the dentist will have pain, but they can receive treatment for that. In the case of sight tests, by the time they make their visit it will too late if the condition has not already been determined.
Another argument for saying that this is a more important amendment is that the sum involved is likely to be in the order of £10 as a starter, compared with £3. It has been argued that £3 is not a deterrent—although I said that it was—but £10 may well be so. I believe that the arguments are overwhelming. Having set off in a healthy track by agreeing to the last amendment, I hope that, without much further ado, the Commmittee will agree the present amendment so ably moved by the noble Lord, Lord Lucas.
§ 5.15 p.m.
The noble Lord, Lord Lucas, would be surprised if I did other than assure him of the full support of my noble friends on these Benches. He has said that the arguments are the same as those put forward in respect of the earlier amendment. Substantially they are, and I do not wish to repeat them because it is unnecessary. They carried weight in the Committee and in the Division Lobby.
There is one marginal difference and I hope that the noble Lord will forgive me for pointing it out. I believe that essential to the amendment is the next clause of the Bill, Clause 14. In the past many routine examinations were carried out by opthalmatrists. They were purely examinations of refraction and many were not as full or as searching as they should have been. Clause 14 gives the Secretary of State rights and powers to prescribe the nature of the examination which is carried out. It would be a mistake for Members of the Committee to believe that in the past the routine eye test has invariably included a test for glaucoma. That is not true, although in some cases it has. I make those comments without fear of contradiction.
There are many ophthalmic opticians who have the necessary apparatus and skills and who carry out the test. However, it is not obligatory under present regulations but it will become so under Clause 14. If the Committee fully supports that clause, which will change the nature of the examinations, it will make wholly valid the arguments put forward earlier by a noble Lord. At the moment they are valid in some cases but not in all.
§ Lord Cullen of Ashbourne
I should like to add my voice to the debate on the amendment. I am worried about the whole clause because I believe that it is 1243 wrong to dismantle or privatise two-thirds of the general ophthalmic services and give the impression that a better system of screening for eye problems and diseases by GPs is being planned when it is clear that that will not happen, as I hope to show.
During the Second Reading debate I inquired about the negotiations which the Government were said to be having with the BMA in respect of this matter. On that occasion my noble friend Lord Skelmersdale assured me that the specific negotiations to which I had referred:have indeed started in the past five days. The more general ones have been going on for some time".—[Official Report, 26/5/88; col. 1090.]I gratefully accept my noble friend's apology contained in his letter to me dated 21st June. He said:I fear that you and indeed other noble Lords may have gained the impression that discussions with the GMSC over screening programmes by GPs for glaucoma and diabetes had started within the five days before the Second Reading debate. That is not so, and I apologise if I have misled you and the House over this point".That was a most misleading remark about a vital issue. I feel sure that my noble friend will wish to make clear to the Committee that what he said was quite inaccurate.
Negotiations with the BMA have not started and it may save time all round if I now give the Committee the text of a resolution passed by the General Medical Services Committee:The GMSC is opposed to the proposals in the Health and Medicines Bill to abolish the universally free NHS sight test. This would, undoubtedly, deter many patients from coming forward for a sight test and there would be a consequential reduction in the detection of eye diseases. The White Paper "Promoting Better Health" made no proposals which indicated that the Government wishes to encourage general medical practitioners to assume responsibilities for general ophthalmic services and the GMSC has no policy to seek such a role for general practitioners".I repeat:the GMSC has no policy to seek such a role for general practitioners".That is a quotation from a letter sent to me from Dr. Michael Wilson, chairman of the BMA's medical services committee, which states very clearly the reaction of GPs to any such proposal. It certainly calls into question any chance of satisfactory negotiations between Her Majesty's Government and the BMA.
I find it impossible to accept the Government's argument that people will not be deterred from going to their optician if they have to pay for a sight test. There will undoubtedly be a psychological deterrent even in the case of those who may be able to afford it. It seems rather strange that a government who believe in the operation of the mechanisms of the market place should seek to deny the deterrent effect of an increase in cost and even more so the imposition of a charge on something which had previously been free.
I am particularly concerned that many elderly people, which is probably the group most at risk, will go without. That is particularly worrying in view of a survey carried out by the British College of Optometrists last January which showed that the over-60s are significantly more likely than younger people to suffer from medical conditions the signs of 1244 which had been observed in the course of the free NHS eye examination.
Many people have tried to make the point that having to pay for sight tests will deter people from having those tests. The Government have doggedly taken the view that that will not happen. The BMA thinks it will; the RNIB thinks it will; and Age Concern thinks it will. All optical bodies are sure it will. However, it is a matter of judgment. We have one on one side and half a dozen on the other. It is difficult to know who is right, but there is a clue. Eleven months ago the Alberta Government imposed charges on people between the ages of 19 and 64—charges which had never been imposed before. Eleven months later, following a decrease in the number of sight tests of about 35 per cent. the Alberta Government have reversed their legislation. That seems to be the best proof that one could have of the deterrent effect of charging for eye tests.
I could go on but I do not think I will. I am very glad to support my noble friend's amendment.
§ Lord Rugby
While we are discussing glaucoma and the various tests required to diagnose the state of glaucoma, should we not be appraised of exactly what are those tests? As I understand it, in the ophthalmic optician's department there are very few people who have any equipment which is capable of testing for glaucoma, even in a fairly primitive way. If one is to carry out the full test, very complicated and expensive equipment is required. Beyond that, there is also required a great deal of background medical knowledge relating to the case history of the person concerned. That would seem to me to be outside the realms of a refraction test.
§ Lord Auckland
I support the amendment very strongly. Quite apart from glaucoma and diabetes—two very serious conditions, made far worse by had eyesight—there are a number of other medical conditions. One of those from which I, like, I am sure, a number of Members of the Committee, suffer, is migraine. As I understand the Bill, migraine sufferers are not excluded from the proposed eye test charges. There are a number of other medical conditions which I could mention, but I shall not weary the Committee in the interests of time.
There is another important aspect. Governments of all parties have spent a lot of money encouraging people to have eye tests. There have been enormous publicity campaigns—and quite rightly. The conditions in Clause 13 of the Bill seem to go well against the grain. Also there are a number of people over the age of 60 who, although they may not be on state-related benefits, will find the cost of the tests very expensive. How much money will be raised by the tests? I believe that the Minister gave a figure, or I have seen a figure quoted, of about £70 million. That is a gross figure.
What is the net figure after all the administration costs which will be needed? I hope that my noble friend will take these matters on board. Of course we need to raise more money for the National Health Service, but I submit to the Committee that we need to do that by far more practical means.
§ 5.30 p.m.
§ Lord Skelmersdale
I appreciate the dilemma in which my noble friend Lord Lucas of Chilworth finds himself in moving this amendment. It is paralleled by my own dilemma to an extent in responding to it. I would argue that irrespective of the arguments for and against charges for teeth inspection, the detail of the health arguments for charging for eye examinations is quite different.
I do not wish to repeat many of the arguments used in responding to the last amendment. But yes, we have indeed been involved in negotiation with doctors on bringing the White Paper into effect. My noble friend Lord Cullen said that he was sure I would take the earliest opportunity on the subject of eye tests to apologise to the Committee and to the Chamber about a remark I made on Second Reading. When referring to discussions with the General Medical Services Committee about the role of general practitioners in glaucoma screening, I said:The specific negotiations to which my noble friend referred have indeed started in the past five days. The more general ones have been going on for some time—. (Oficial Report, 26/5/88: col. 1090.)I accept that I was wrong in making that pronouncement. I was aware that the general issue of glaucoma screening and other screening by GPs was under discussion but not, I admit, in that particular forum. I therefore apologise for misleading the Committee in that regard.
Not surprisingly, much of this debate has centred on glaucoma; and diabetes mellitus is another disease which can be picked up through examination of the eye. Some noble Lords would argue that those diseases are so serious, as they affect people's sight, that that alone knocks for six the principle of charging. I accept, as I did earlier, that these diseases can be identified by sight testing in many instances. However, this time I suggest that it depends not on two factors but on three—the fact that practitioners do detect them; the fact that people have their eyes tested; and, finally, the fact that they have them tested at the right time to show up those diseases.
The noble Lord, Lord Winstanley, mentioned a sometimes little referred to proposal in the Bill that we intend to specify in regulations what should go into the standard eye test. That we fully intend to do. It is found in Clause 14, page 18 line 3 (the new Section 20B(1)(a) in the Opticians Act); again on page 15, line 7; and, the Scottish equivalent, page 17 line 28.
It is important to realise that we cannot guarantee now that people have their eyes tested at all. Of course we have never had any control over that. Nor can we now, under the proposed arrangements, ensure that people present themselves for eye tests at the time when glaucoma, the effects of diabetes, or any other disease of the eyeball or socket are visible to the practitioner, even under a well-conducted statutory eye test. Those two factors therefore will not change.
What we can do is make it easier for people who have, or may have, those particular diseases of the eye to present themselves more readily by giving them free eye tests. We gave an assurance in another place that that is what we would do. Today I am able to go 1246 further and announce that we will lay regulations to give free tests to children and siblings of known glaucoma sufferers who are 40 or over.
Having said that, I believe that we must put this issue of glaucoma into proportion. It is principally an hereditary disease. The risk for close relatives of glaucoma is 10 times greater than for those who are not known to have such a relative. While it is estimated that 5 per cent. of those relatives over-40 will develop the condition, only half of 1 per cent. of the rest of the over-40 population will do so. Of the 5 per cent., 5 per cent. will be new cases.
We cannot guarantee to pick up that small number of people now, so we do not suggest that charges will make it any more or less likely, but we shall do so in future. Criticism of our proposals is again based on the fear that people will be deterred by price from having private sights tests and as a consequence eye conditions such as glaucoma will go undetected or be detected only at a later stage when treatment may be less effective. At this time it must he a matter of judgment what effect our proposals will have on the number of sight tests.
My noble friend Lord Cullen referred to the situation in Alberta, Canada. I understand that the letter from the profession in Alberta accepts that there is no statistical evidence available. The claim of 30 per cent. to 40 per cent. reduction in eye tests seems to be based on anecdotal evidence. However, as I said in answer to the last amendment, it would not be surprising if there was a temporary drop in the early days of charging. People who knew that the change was coming would bring forward their tests to avoid the charge. That does not mean that they will avoid the charge in future. In the letter there is no mention of exemptions, which are well understood in our proposals.
The experience of our spectacles measures shows that replacing the National Health Service with private supply has not resulted in fewer visits to opticians and that competition has resulted in reasonable spectacle prices for the consumer. A recent survey shows that in the United Kingdom retail sales of spectacles have increased by about 10 per cent. from £250 million in 1984 to £270 million in 1986. In that same period the annual number of sight tests increased by nearly 1 million. We see no reason why this trend should not continue.
Finally, my noble friend Lord Cullen referred to the concerns expressed by the General Medical Services Council. My right honourable friend the Minister for Health replied to its letter on these concerns on 8th July. He said:The Government do not envisage screening programmes for diabetes and glaucoma of the systematic call and recall kind developed for breast and cervical cancer. What we certainly do envisage, however, is encouraging practices to take a more systematic interest in identifying potential problems of which the patients themselves may not yet he aware. I made several references during the Committee debates to the leaflet of a practice which actively urges patients aged 30 to 65 to come and have their blood pressure checked at least every five years and I believe the same practice also seeks to identify diabetics. We want to encourage this kind of approach especially in relation to elderly patients. For example, if a general practitioner thinks it is desirable for a patient to be assessed for glaucoma a referral for eye examination would be the right course".1247 In conclusion, it is necessary in consideration of this issue to look at the Government's total revised proposals under these two clauses. The priority groups will be protected, and we have already responded to the fears expressed. It should be remembered that many groups will continue to be entitled to free National Health Service sight tests on income or clinical grounds: children under 16; full-time students under 19; people on family credit; people on income support; those with incomes a little above the qualifying level; the registered blind and partially sighted; people who are entitled to a NHS spectacle voucher for contact lenses; diabetics or people with glaucoma who are referred for tests by the doctor or clinic managing their condition; and the children and siblings of people with glaucoma who are 40 years and over.
In all, between 19 million and 20 million people will be covered by these arrangements. The others are well able to afford the modest cost of a sight test and I believe it is right to ask them to do so to help fund the development of our primary care services which have been generally welcomed.
My noble friend Lord Auckland asked how much we expect to receive from this, net. The answer is the £70 million to which I referred, because there are no extra costs involved in collecting this money—we simply will not be paying it out. Therefore if anything the net receipt is marginally above the figure I have mentioned.
It has been suggested that the hospital eye services will be overloaded, but I believe I dealt with that point on Second Reading. I do not believe that will be so. Doctors will only refer, as now, people to the hospital eye service who require that service for medical needs as identified by the doctor.
§ Lord Lucas of Chilworth
I greatly admire the manner in which my noble friend has dealt with this part of our debate. I am sorry that he did not follow my example by being less wearisome to the Committee since we have dealt with the problem. I do not propose to comment further. I have made my observations, as have other Members of the Committee. They stand on the record and I press the amendment standing in my name.
§ 5.40 p.m.
§ On Question, Whether the said amendment (No. 34) shall be agreed to?
§ Their Lordships divided: Contents, 120; Not-Contents, 94.1249
|DIVISION NO. 2|
|Addington, L.||Bonham-Carter, L.|
|Adrian, L.||Bottomley, L.|
|Airedale, L.||Brain, L.|
|Ardwick, L.||Brooks of Tremorfa, L.|
|Auckland, L.||Brougham and Vaux, L.|
|Aylestone, L.||Bruce of Donington, L.|
|Banks, L.||Carmichael of Kelvingrove, L.|
|Birk, B.||Carter, L.|
|Blackstone, B.||Chelwood, L.|
|Blease, L.||Cledwyn of Penrhos, L.|
|Cocks of Hartcliffe, L.||McGregor of Durris, L.|
|Colwyn, L.||McIntosh of Haringey, L.|
|Cornwallis, L.||McNair, L.|
|Craigavon, V.||Masham of Ilton, B.|
|Cudlipp, L.||Mason of Barnsley, L.|
|Cullen of Ashbourne, L.||Mayhew, L.|
|Darcy (de Knayth), B.||Molloy, L.|
|Davies of Penrhys, L.||Morton of Shuna, L.|
|Dean of Beswick, L.||Mountbatten of Burma, C.|
|Donaldson of Kingsbridge, L.||Mulley, L.|
|Dormand of Easington, L.||Nicol, B.|
|Elliot of Harwood, B.||Oram, L.|
|Elwyn-Jones, L.||Parry, L.|
|Ennals, L.||Peston, L.|
|Ewart-Biggs, B.||Prys-Davies, L.|
|Faithfull, B.||Raglan, L.|
|Falkender, B.||Rankeillour, L.|
|Falkland, V.||Rea, L.|
|Fisher of Rednal, B.||Ritchie of Dundee, L.|
|Foot, L.||Robertson of Oakridge, L.|
|Fortescue, E.||Rochester, L.|
|Gallacher, L.||Saltoun of Abernethy, Ly.|
|Galpern, L.||Seear, B.|
|Gardner of Parkes, B.||Seebohm, L.|
|Glenamara, L.||Serota, B.|
|Graham of Edmonton, L. [Teller.]||Shackleton, L.|
|Greenway, L.||Simon, V.|
|Halsbury, E.||Somers, L.|
|Hampton, L.||Stallard, L.|
|Harris of Greenwich, L.||Stedman, B.|
|Hart of South Lanark, B.||Stoddart of Swindon, L.|
|Hatch of Lusby, L.||Strabolgi, L.|
|Henderson of Brompton, L.||Strathcarron, L.|
|Hooson, L.||Taylor of Blackburn, L.|
|Howie of Troon, L.||Taylor of Gryfe, L.|
|Hughes, L.||Taylor of Mansfield, L.|
|Hunt, L.||Teviot, L.|
|Hunter of Newington, L.||Thurlow, L.|
|Hutchinson of Lullington, L.||Tonypandy, V.|
|Hylton-Foster, B.||Tordoff, L.|
|Jacques, L.||Turner of Camden, B.|
|Jeger, B.||Underhill, L.|
|Kennet, L.||Vernon, L.|
|Killearn, L.||Wallace of Coslany, L.|
|Kirkhill, L.||Wells-Pestell, L.|
|Lawrence, L.||Whaddon, L.|
|Lloyd of Hampstead, L.||White, B.|
|Longford, E.||Willis, L.|
|Lovell-Davis, L.||Winstanley, L.|
|Lucas of Chilworth, L. [Teller.]|
|Allerton, L.||Davidson, V. [Teller.]|
|Arran, E.||Denham, L. [Teller.]|
|Balfour, E.||Donegall, M.|
|Bauer, L.||Dormer, L.|
|Beaverbrook, L.||Dundee, E.|
|Belhaven and Stenton, L.||Elliott of Morpeth, L.|
|Beloff, L.||Fanshawe of Richmond, L.|
|Belstead, L.||Ferrers, E.|
|Bessborough, E.||Gisborough, L.|
|Blatch, B.||Glenarthur, L.|
|Boardman, L.||Grantchester, L.|
|Borthwick, L.||Grimston of Westbury, L.|
|Brabazon of Tara, L.||Hailsham of Saint Marylebone, L.|
|Broxbourne, L.||Hardinge of Penshurst, L.|
|Bruce-Gardyne, L.||Harmar-Nicholls, L.|
|Burton, L.||Harvington, L.|
|Caithness, E.||Hesketh, L.|
|Cameron of Lochbroom, L.||Hives, L.|
|Carnegy of Lour, B.||Holderness, L.|
|Carnock, L.||Home of the Hirsel, L.|
|Cathcart, E.||Hood, V.|
|Clitheroe, L.||Hooper, B.|
|Coleraine, L.||Johnston of Rockport, L.|
|Colville of Culross, V.||Joseph, L.|
|Constantine of Stanmore, L.||Kimball, L.|
|Craigmyle, L.||Kitchener, E.|
|Layton, L.||Reigate, L.|
|Lindsey and Abingdon, E.||Richardson, L.|
|Long, V.||Rochdale, V.|
|Luke, L.||Rodney, L.|
|McFadzean, L.||Rugby, L.|
|Mackay of Clashfern, L.||St. Aldwyn, E.|
|Marley, L.||St. Davids, V.|
|Merrivale, L.||Sanderson of Bowden, L.|
|Monk Bretton, L.||Savile, L.|
|Montgomery of Alamein, V.||Skelmersdale, L.|
|Mowbray and Stourton, L.||Strathspey, L.|
|Munster, E.||Sudeley, L.|
|Nelson, E.||Swinfen, L.|
|Newall, L.||Swinton, E.|
|Norfolk, D.||Thomas of Gwydir, L.|
|Nugent of Guildford, L.||Torhichen, L.|
|Orkney, E.||Trafford, L.|
|Orr-Ewing, L.||Trumpington, B.|
|Oxfuird, V.||Whitelaw, V.|
|Peyton of Yeovil, L.||Windlesham, L.|
§ Resolved in the affirmative, and amendment agreed to accordingly.
§ 5.48 p.m.
§ The Deputy Chairman of Committees (Lord Alport)
I was under a misapprehension. I was wrong in saying that Amendments Nos. 35 to 44 fell; it was Amendments Nos. 35 to 41. Therefore we now turn to Amendment No. 42 in the name of the noble Lord, Lord Winstanley.
I am not sure that that is right. I believe that the Minister is anxious to be helpful because he usually is. However, in order to speak at all I move Amendment No. 42 in my name.Page 13, line 32, leave out ("19") and insert ("22").The noble Lord said: If the Minister wishes to intervene at this stage it may be helpful.
§ Lord Skelmersdale
As I understand it Amendments Nos. 42 and 47 fall to be discussed en bloc. They seek to extend the scope of the free sight test but since free sight tests have already disappeared, it would be appropriate not to move this amendment.
Having formally moved the amendment and in order to enable the Minister to assist me, I request leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendments Nos. 43, 43A, 43B and 44 not moved.]
Lord Lucas of Chilworth moved Amendment No. 45:
Page 15, line 11, leave out subsection (2).
§ The noble Lord said: I have already spoken to this amendment with Amendment No. 34. I beg to move.
§ On Question, amendment agreed to.
§ [Amendments Nos. 45A to 45C not moved.]1250
Lord Lucas of Chilworth moved Amendment No. 46:
Page 15, line 41, leave out subsection (4).
§ The noble Lord said: I spoke to this amendment with Amendment No. 34. I beg to move.
§ On Question, amendment agreed to.
§ [Amendments Nos. 46A to 47E not moved.]
Lord Winstanley moved Amendment No. 48:
Page 17, line 45, at end insert—
("( ) References to optical appliances in the National Health Service Act 1977 or the National Health Service (Scotland) Act 1978 shall not include any appliance designed to correct, remedy or relieve a gradual diminution in the focusing power of the eye which is wholly attributable to the condition known as presbyopia and—
§ The noble Lord said: We have arrived at an amendment which has not been overtaken by our previous success. The amendment refers to a related but rather different matter. It is a controversial one, and I think I am right in saying that even though I speak from the Front Bench today it does not necessarily follow that all my noble friends on these Benches will wish to support the amendment. I also understand that noble Lords on the other side of the Committee will have a free vote on this matter.
§ As people have been so heavily lobbied by various interests, perhaps I may make it absolutely clear that I have no interest to declare in any of the companies or firms which would benefit or would not benefit, as the case may be. I move this amendment because 1 believe that it is a wise provision. What is it about? I have always believed that the requirement that elderly people who gradually suffer from presbyopia —in other words, they gradually become long-sighted and merely need magnifying lenses—should have a full ophthalmic examination before being allowed to buy magnifying lenses is about as sensible as insisting on their having a full orthopaedic examination before being allowed to buy a walking stick.
I know that there are other views on this matter but I want to make it absolutely clear, as I hope it is by now from discussion on previous parts of the Bill, that I am wholly in favour of people having regular eye tests. I have said not once but time and again that as a general practitioner I depended deeply on local opticians. I frequently sought their advice about patients and I frequently referred my patients to them.
I am also aware that the examinations carried out by optometrists occasionally disclose certain other diseases such as glaucoma. I say "occasionally", reverting to something I said previously in relation to the amendment of the noble Lord, Lord Lucas of Chilworth. The importance of that amendment 1251 depended on the next clause of the Bill, Clause 14, which enables the Secretary of State to make regulations with regard to the nature of the examination which is carried out by the optometrist or by the ophthalmic optician. In many cases those examinations are purely superficial and consist merely of refraction and nothing else. It would be misleading for the general public to think that every visit to an optician for refraction necessarily includes detailed examination of the eyes in order to detect these other matters.
I accept that many ophthalmic opticians carry out those examinations and have the equipment to do so. I also accept that Clause 14 of the Bill enables the Secretary of State to make regulations which will improve the general standards of those examinations. In general I believe that the more important diagnostic work is done by the eye hospitals, by the ophthalmic medical practitioners and in other ways. However, I do not for a moment take away from the excellent work done by many of the opticians, some of whom have complained about this amendment and some of whom have not.
People are on different sides in this matter. I have been advised by senior consultant ophthalmologists. At least three have said that they support my amendment, and I am aware that others do not. It may be of interest to the Committee to know that I have had letters from a married couple, both of whom are ophthalmic medical practitioners. One is wholly in favour of my amendment and the other is opposed to it. It shows that there is a reason for argument; and why not?
I should like to make it absolutely clear that there is no evidence that wearing the wrong spectacles does anybody the slightest harm. It is true that one might not be able to see and that one might be run over, or something of that kind. However no medical harm results directly from wearing the wrong spectacles. In my period in general medical practice I saw that in some families glasses were handed down from the eldest member of the family to the next, and so on, as people's eyes progressively changed with age. They did not necessarily have the best possible glasses but at least they had glasses through which they could see. Using those glasses did them no harm whatsoever.
What does my amendment seek to do'? The amendment is rather complicated. Some Members of the Committee will recollect that originally I tabled a much simpler amendment which I withdrew on the advice of officials within the department. They told me that it would be better if I used the wording which they devised. I do not fully understand this wording but they tell me that this wording achieves my object, which is merely to enable people to purchase simple magnifying lenses—spectacles—containing two equal lenses of certain limited diopters without ophthalmic examination. I see no dangers arising from that and I see a great deal of convenience to many people who will be able to go in and choose spectacles which suit them for those purposes.
1252 It is not my object to deter people from having regular ophthalmic examinations. I believe that they should have them. It is my purpose to try to make things simpler for a whole group of people who I am quite sure would benefit from this simple provision. It has been discussed over many years not only in this Chamber but in another place. I should like to hear what is now the department's attitude to this possible development and what other Members of the Committee may think. Although I know what some Members think, I do not always agree with them. I beg to move.
§ Lord Bruce-Gardyne
I strongly support the argument advanced by the noble Lord. Perhaps I should start by making it quite clear that I have no interest to declare either, except that I must confess to the Committee that I come before it this evening in the posture of a felon. My glasses, I regret to say, were acquired without the benefit of prescription. I went into a shop—not on the other side of the Atlantic but not a thousand miles from this Chamber—where I was presented with a board with script upon it in different sizes. I was invited to choose a pair of glasses and I did so. We have lived happily together ever after—for a period of some 18 months. I have no doubt that I have broken the law and I suppose that if I am not careful I shall have the long arm of the law upon me.
What concerns me about the present position is that it is possible for any Member of the Committee to visit the same establishment. It is still, so far as I know, in business and there are a number of such establishments round the country. However, as the law stands at present they are constantly under threat of being challenged by the authorities in the profession who can fairly easily demonstrate that the establishments are selling spectacles without the benefit of prescription. They can then be drummed out of business. The consequence is that many of our fellow citizens who, like me and, I venture to suggest, a large number of Members of the Committee, suffer from the sad effects of advancing years upon our ability to read, are denied the facility and convenience which comes from our being able to go to a shop and buy our spectacles over the counter—the practice, as we all know, for many years in most other countries.
I listened carefully to what my noble friend the Minister said on the earlier amendment which was carried by the Committee. I do not think I would be maltreating his arguments if I ventured to suggest that he demonstrated most clearly that the connection which tends to be advanced between detection and prevention of diseases like glaucoma through sight testing is at best a somewhat tenuous one. The real reason, I submit—I think we all know this -for the obligation upon those who wish to have reading glasses first to obtain a valid prescription appearing in the substantive legislation was that it was a special concession to the optical profession at the moment when its monopoly was being withdrawn.
In practice, I submit, it has not worked out satisfactorily even from the point of view of the opticians. The individual is given a sight test, then 1253 takes his prescription round the corner to a general emporium where he can buy his glasses. Understandably, the opticians are resentful about that practice, but it is entirely within the scope of the law.
I submit to the Committee that by carrying this amendment, moved so effectively by the noble Lord opposite, we will eliminate an anomaly, simplify greatly the lives of many of our fellow citizens and add—so far as one can by changing the law—to the sum total of human satisfaction. Therefore I hope that we shall do that tonight.
§ 6 p.m.
§ Lord Rugby
I regard myself as having been singularly unfortunate in life in that the Opticians Act 1958 applied at the very moment that I was entering what is known as the presbyopic age; that is, around 45. Therefore, if one takes the seven ages of man as portrayed by Shakespeare there are at least three which could be the presbyopic age. There is early middle age; there is advanced middle age; and there is old age. The three ages amount to almost half of one's life. Throughout, one is subjected to a compulsory sight test merely in order to cater for the perfectly normal progression of one's age, which is presbyopia. At certain times one might not need very strong spectacles. But as one goes through life one might need slightly stronger ones.
When what became the 1958 Act was going through this House under the auspices of the noble Lord, Lord Crook, he stood up and said that if people were permitted to choose their glasses, as they had done previously, they would be in serious danger of going blind. Because of that the spectacles were taken off the market and put on to the health service. I believe that a great injustice was done. The presbyopic person—that is, the middle aged, the advanced middle aged or the elderly—must now have the right restored to him to cater for advancing disability by being able to choose his own reading glasses.
§ Lord Hunter of Newington
The noble Lord, Lord Winstanley, and others have argued eloquently that there should be unrestricted sale without prescription of ready-made spectacles. There was a time when 1 had a good deal of sympathy with the proposal, but I have changed my views. I should explain why. I do not think there is much in this from the point of view of cost. I am assured that properly prescribed spectacles made to the appropriate British standards are available at prices in the same range as, or below, those governing ready-made spectacles.
So, why have I changed my view? A patient with an ophthalmic problem, as we have heard this afternoon, has a choice at the moment as to where he 1254 seeks advice. For example, he may choose to consult a general practitioner, an ophthalmic optician or an ophthalmic medical practitioner. He may also attend the eye hospital casualty department. Studies have shown that for many patients the eye hospital casualty department is where ohpthalmic primary care is provided. Ophthalmic medical practitioners provide care under the general ophthalmic services, usually on the premises of dispensing or ophthalmic opticians.
A recent study has shown, as has been said, that above the age of 54 all patients require spectacle correction. However, there are many sight-threatening conditions which are symptomless to the patient in the early stages but which can he picked up by opticians. The important change which has taken place is that with new technology, glaucoma, diabetic retinopathy and macular degeneration—mentioned once, by the noble Lord, Lord Ennals—can be detected. Treatment in the early stages can prevent significant sight loss.
In 1980 glaucoma caused several thousand people to lose their sight. Diabetes is the commonest cause of blindness in the United Kingdom, but 70 per cent. of diabetic blindness is now preventable. Macular degeneration is responsible for 50 per cent. of blind registrations after the age of 65. Identification within the first few weeks is essential if treatment is to be effective. Laser techniques are developing rapidly and there is a high success rate, with patients often retaining useful vision for the rest of their lives. Perhaps this group is the most urgently in need of early diagnosis and treatment.
§ Lord Orr-Ewing
I should like to express my support for the amendment. Like the noble Lord, Lord Winstanley, I have been concerned with this matter for some 30 years. It is interesting that extra enthusiasm for it was triggered when the EC exposed the fact that a pair of glasses is not really a medical appliance and that it was perfectly natural for people to buy glasses as they do throughout the OECD countries and as they do in America in all but two states. Everyone is allowed to do so. All those countries are just as careful about people's eyesight and have technology which is as good as that we have here. Therefore, I cannot see why we should superimpose a continuing burden from Nye Bevan's day when it arose for good reasons, which no longer exist.
I should not like to argue with the noble Lord who has just sat down because he has so much more experience in this field. But certainly the arguments put forward up till now say that glaucoma will be detected. The noble Lord, Lord Winstanley, exposed that and I have discussed the matter with other specialists—optical surgeons of the highest calibre and experience. All say that what is so sad is that something like 90 per cent. of the people referred to them have the wind put up them. They think, "Good gracious, I am going to go blind. I shall have glaucoma or something incurable", and so on. That is totally unnecessary because the people who are testing do not have the experience to justify the diagnosis. Therefore people are unnecessarily alarmed. I am afraid that emotion plays a part in this; 1255 indeed, it would affect anyone. For example, if one was asked unscrupulously, "Well, wouldn't you sacrifice some extra money for a few more tests, if you somehow put off the moment when you went blind?" it would alarm one to such an extent that one would stop at nothing. The noble Lord, Lord Hunter of Newington, said that that condition would be detected. If it would be, why has every other nation abolished the monopoly of insisting on a prescription test? Would they all not be doing this? Why has the EC said that it will not carry out the tests which do not involve medical equipment. It is natural for everyone to need spectacles when they reach the age of 45.
I have a caretaker at home when I am in this place. I saw her wearing a new pair of spectacles last weekend. I asked her how much they had cost. She told me that she had paid £69. I asked her whether she knew how much the spectacles I was wearing cost and told her that they had cost £23.50 with VAT. I am afraid that the man who supplied them to me has been closed down after threats from solicitors and many others who uphold the monopoly. There must be a great deal of money to be made in opticians' shops. One has only to walk down a high street, as I do in Newbury or Thatcham, and almost every time there will be a new opticians' shop tempting one inside. They would not be doing it if there were no profit in it.
We should be able to buy spectacles in this country from £9 as they can in every other advanced country. My good friend at home told me that she had bought a rather better pair of spectacles because she was paying for the frame. That is good salesmanship. One puts the ugly frames on the cheap spectacles and the more gracious frames on the expensive spectacles, charges three times as much as is necessary and makes three times as much profit.
I hope that after all the arguments and the testing of the semi-monopoly that has existed since the end of the war we shall do what other nations have done and shall pass the amendment.
§ Lord Monson
When introducing Amendment No. 34, the noble Lord, Lord Lucas of Chilworth, spoke of "eye disease" starting between the ages of 45 and 50. A tiny minority of unfortunate individuals may contract an eye disease at that time, but, as has been pointed out, the condition which leads most people to start needing reading glasses sometime between the ages of 45 and 55 (presbyopia) is no more a disease than one's hair thinning or growing grey between those ages is a disease.
The term "patient" so beloved by opticians, which enables them to justify every type of mystique and pretension of quasi-medical professionalism, is entirely inappropriate to describe purchasers of simple reading spectacles. As the noble Lord, Lord Orr-Ewing pointed out, that was confirmed by the recent EC ruling. On previous occasions the Government have admitted that no harm can result from the purchase of reading glasses without a prescription, but they try to justify the compulsory eye test on the grounds that glaucoma might be detected as a by-product of the test.
1256 As the noble Lords, Lord Rugby and Lord Winstanley—who knows what he is talking about—pointed out, only a minority of eye tests are capable of detecting glaucoma. I believe that that answers the point made by my noble friend. The Minister has reminded us how few non-hereditary cases of glaucoma are found. All sorts of diseases in adults remain undetected for years. That is part of the price one pays for a free society. If every adult were compelled by law to submit to a full hospital checkup every three to five years there might be some logic in the arguments of the opponents of the amendment. It is no more logical to require those buying reading glasses to submit to an eye test than it would be to require those buying calamine lotion to submit to tests for skin cancer or to require those trying to buy a packet of aspirin for a headache to submit to a brain scan. Highly civilised and advanced countries such as the United States and Canada permit glasses such as the ones I bought in Toronto for about £9.50 to be sold across the counter. Why cannot we be as civilised and progressive as the United States and Canada?
§ 6.15 p.m.
§ Lord Rea
I do not have any strong feelings about the amendment. Once while I was in the United States I benefited when I left my glasses on top of my car and drove off. I was able to buy a new pair over the counter. Perhaps the noble Lord, Lord Winstanley, can answer my question. Many of the conditions which are detected by the screening by opticians occur at the ages when presbyopia appears. If someone has developing glaucoma or macular degeneration when presbyopia is also developing and he buys spectacles over the counter, he will experience a degree of improvement in his vision. Will that not put him off going for the treatment which the early condition needs?
Perhaps I may answer, as the question has been put to me directly. No, I do not think that it will. If I thought that it would, I should have second thoughts. I merely seek to enable people to obtain simple magnifying lenses, as the noble Lord did in America when he left his spectacles on the top of his car.
I believe that the safety net which has been referred to—the testing, screening and weeding out of other conditions—which we are alleged to have had in the past has been nothing like as safe as has been made out. That is why I so warmly welcome Clause 14, which gives the Secretary of State powers to change the nature of the eye test. It is faintly misleading, and gives people a false sense of security if they believe that a simple test for infraction optometry gives them automatic screening in relation to various diseases.
I am in favour of people having their eyes looked at regularly. I am in favour of certain people having their eyes looked at by ophthalmic medical practitioners or perhaps even at an eye clinic; but I do not believe that the ability to buy simple magnifying lenses without a prescription will prevent people from having that kind of regular supervision.
§ Lord Cullen of Ashbourne
I find it difficult to accept what the noble Lord has just said. If so-called 1257 ready-made spectacles are legalised, it will encourage people not to have eye tests. If they think that there is something not too good about their eyes they will go to one of those shops and pick up a cheap pair of spectacles. One scrabbles about and finds a pair of spectacles that makes one see rather better. That does not necessarily mean that one sees as well as one should, which is important. There is not only the medical aspect of people not being screened for disease: they will not see as well and as comfortably as they should when their spectacles are not of the proper quality.
It seems like old times to be discussing ready-made spectacles. We have done it so often in the past eight years or so; usually at the instance of the noble Lord, Lord Rugby, supported by my noble and old friend Lord Orr-Ewing. I sometimes wonder from where he obtains his spectacles. He and the noble Lord, Lord Rugby, do not seem to like opticians very much.
§ Lord Orr-Ewing
It is not that I dislike opticians. I wish to give the public the benefit of new practices and cheaper glasses. I should like the millions of people to benefit rather than selected opticians.
§ Lord Cullen of Ashbourne
I could not agree more about that. One of the great things about the present arrangement is that one can now obtain budget glasses from any optician at about £15.50. That is what it costs with a voucher which a fortunate 30 per cent. obtain free. Magnavision, a firm which has been illegally selling reading glasses for the past three or four years is now charging £17.50 or £19. The managing director recently said that there was no way in which they could reduce their prices and make a profit.
I entirely agree with my noble friend. We must have the best quality glasses at the most reasonable prices. That is what is happening at the moment. I cannot agree with the noble Lord, Lord Winstanley. I was interested to hear that the noble Lord, Lord Hunter, with all his experience, does not agree either. I certainly hope that the Committee will not agree to this amendment.
§ Lord Monson
Before the noble Lord, Lord Cullen, sits down, would he not concede that his argument in reality is an argument that all medicines, including analgesics and stomach remedies, should be sold on prescription only?
§ Lord Monson
Is not the noble Lord's argument in effect an argument that all medicines of every sort should be sold only on prescription?
§ Lord Cullen of Ashbourne
I do not think so. I am simply saying that a test is a very good thing. It is good for people to have their eyes looked at, say, every couple of years. If one legalises ready-made spectacles it will simply discourage people from having tests. If people can see perfectly well with something that they have picked up, for years they will go from one ready-made pair of spectacles to 1258 another as their eyes become steadily poorer. They will not go near an optician or have a proper eye examination.
§ Lord Rugby
Is the noble Lord suggesting compulsory medication for people who have no desire to have that medication by compelling them to go and have their eyes tested by people with whom they do not wish to do business?
§ Lord Nugent of Guildford
Perhaps I may add one further word to this interesting debate. For the sake of my noble friend on the Front Bench I could have wished that this amendment had been taken before the last one since it might have changed the voting. I am someone who has his eyes tested regularly and I believe in getting a prescription. In fact, although I see reasonably well one of my eyes is slightly different from the other and so I need two somewhat different lenses. I agree with my noble friend Lord Cullen that legalising ready-made spectacles will undoubtedly encourage people not to have tests. Of course it will.
I should have thought that that would be moving in the opposite direction to the way in which we wished to go. I still believe that a £3 charge would not stop anybody from having the test, but I shall not go over that argument again. However, it is curious that we seem to have moved round in a circle. I am very glad to find myself in step with my noble friend Lord Cullen because I believe that on balance the arguments come down in favour of retaining the present law, especially if it encourages people to have tests.
I do not know whether the Government will leave the Bill amended as it is, but if they do not or if the Bill proceeds anyhow I should have thought that competition in the field of sale is such that more and more opticians will reduce the cost of testing and will throw that in, so to speak, with the sale of the spectacles. I do not believe that there is any harm in keeping the law as it is if it encourages people to continue to have tests.
§ Lord Ardwick
Speaking from personal experience, my own glasses cost £24, which I believe is the same as the noble Lord paid for his spectacles. I also have one eye which is different from the other and my reserve spectacles—my secondary paircost £17.
§ Lord Lucas of Chilworth
Perhaps I may come in on this discussion, although I certainly do not intend to be anecdotal. I oppose the amendment of the noble Lord, Lord Winstanley. I noticed when he was speaking that he said that what he wanted to do was to make available a simple magnifying lens. I do not know how he will do that with this amendment. It seems to me that the amendment would allow ready-made spectacles of wide varieties of shapes, sizes and distances off the nose and so on, all of which have a bearing on seeing.
I do not want to go back over the necessity of having a test. Certainly I refute the suggestion of the noble Lord, Lord Rugby, who said, "But these people don't have the equipment to do it". I am not sure that he is absolutely right about that. Ophthalmic prescribing doctors, as I think they are 1259 called, and the ophthalmic optician are increasingly taking advantage of the new technologies and are equipping themselves. That is not to say that they can diagnose immediately from an eye test that such a person suffers from something. They can diagnose that something is wrong. They know when someone does not see straight and can deal with that, but they also realise that something else may be wrong. It may be that the pressure is not right or it may be a question of general health. They advise a visit to the doctor. That is how it goes.
I am very surprised that, particularly from where he sits, my noble friend Lord Orr-Ewing should cast aspersions upon the profit motive. I know Thatcham. I do not know that new opticians' shops are opening every week in Newbury and Thatcham. The signs may change over the shops and so may the windows and the displays. The Government are continually telling us the same story, and they repeated it about car repairs the other day: shop around for a bargain. The market place for spectacle frames is wide open and working.
No, I did not intend to be anecdotal and I shall not repeat any anecdotes; but I know that not many yards from here one can get a very nice pair of spectacle frames for £18 and it costs £7 or £8 for a simple lens. The whole thing costs about £25. The noble Lord, Lord Orr-Ewing, and those who support the noble Lord, Lord Winstanley, have totally failed to demonstrate where the benefit lies and to whom it falls. There is no consumer benefit and there is no price benefit. I have evidence of being able to buy spectacles—not in Hong Kong and not a thousand miles away—in the lower price ranges, say, for under £20. It can be done if one shops around.
Not only have the noble Lords failed to demonstrate the benefit but they have all left open the one matter which the Committee decided in two Divisions earlier this afternoon when it agreed that screening was necessary. This amendment precludes that screening by virtue of what is on sale. There is then a health risk so there is a disadvantage.
§ Lord Bruce-Gardyne
I am grateful to my noble friend for giving way. Before he sits down I should like to reply to the point he made when he said that we have been unable to demonstrate in this amendment any consumer benefit.
Has my noble friend never experienced—as I certainly have on more than one occasion—the appalling situation of losing one's glasses, as one noble Lord opposite confessed? In the days before there were shops which offered glasses over the counter one sometimes had to wait days before one could obtain a replacement, and during the interval one could not even read adequately. I have experienced that more than once. I find it incredible that anyone can suggest that there is not a consumer advantage in being able to find a shop at which one can obtain the necessary implement across the counter.
§ Lord Lucas of Chilworth
If the noble Lord asks me a direct question I can tell him that I have lost my spectacles on more than one occasion. Most 1260 frequently I leave them in the Library. I then go to Mr. Scott's office and he says, "Here is a drawer full, my Lord. Will you choose one that will do?" So I take the spectacles and perch them on the end of my nose. I then ring up my supplier and say, "You have my prescription and I want exactly the same thing. How much will they be and when can I have them?" I can obtain a pair within 24 hours if I like to pay a little premium. I can get them in a week if I like to pay a little less. I think that is the market place.
§ Lord Ardwick
I too have sometimes lost my spectacles. On two occasions I have gone into an ordinary opticians who supplied me with a pair of some kind with which I could carry on until I could have proper spectacles made.
§ Lord Trafford
We seem to be going round in circles, as my noble friend said. It is true that screening is useful and that we wish to encourage people to attend for eye tests. Earlier today the Committee agreed that they should remain free of charge. The noble Lord, Lord Winstanley, who moved that amendment, said that it encouraged people to go and have eye tests.
Why do people have eye tests at all? In 90 per cent. of cases it is for the reason that we heard from the noble Lord, Lord Bruce-Gardyne-namely, that they cannot see quite so well as they used to, and that their arm is no longer long enough to hold the London telephone directory. Therefore, they go to their doctor or their optician and have an eye test. That is the main reason why people ever have an eye test.
All the diseases that were mentioned by the noble Lords, Lord Hunter and Lord Rea, are symptomless. But they may be found when a person who needs magnification through lenses goes to the optician because he is having difficulty seeing. It does not seem to me logical that we can possibly agree to this amendment having just passed the previous one.
I opposed the previous amendment on the grounds that I did not see anything wrong with charges. I have made that absolutely clear. It was clear that the majority of the Members of the Committee did not agree with me. That is fair enough, but I cannot see the logic of the Committee passing two amendments which propose the encouragement of screening and testing then turning round and saying, "Let's not bother with all this. Let's just go down the road and let's hope that by putting a couple of lenses in and reading the big letters and the little letters we can put it right." To do that in the presence of eye disease would be to stick one's head in the sand. One would suffer worse troubles if one lost one's glasses in those circumstances than the noble Lord, Lord Winstanley, suggested. He might not know which lamppost he would hit. That situation can arise from a number of circumstances. Therefore, it appears to me that it is not logical for the Committee to pass this amendment having rejected the other two.
§ 6.30 p.m.
§ Lord Monson
The answer to the noble Lord is that the free screening for which the Committee has voted twice this afternoon is voluntary and not compulsory. That is the whole point.
§ Lord Skelmersdale
If I may, I shall put the Government's view on this amendment before the Committee. Clearly the arguments on both sides of this particular amendment run thick and fast. In the circumstances, the Government wish to be guided by the views of the Committee on whether the prescription requirement should be retained or not.
If this matter comes to a vote today, which, incidentally, I hope it will not for reasons that I shall shortly explain, Members on this side of the Committee will be free to vote according to their own judgment upon the principle of whether or not the unrestricted sale of equal dioptre lensed spectacles should be allowed without presentation of a prescription.
No one, with the partial exception of my noble friend Lord Lucas of Chilworth, has so far mentioned the detail of the amendment. The noble Lord, Lord Winstanley, said that it was put down on advice from someone in my department. Those were very vague words and I do not know who that person could he. However, I can say that the advice was not given with the knowledge of the parliamentary draftsmen. I say that because the detail of the amendent before us today is unacceptable to the Government for three reasons. First, it would be impossible for a supplier to identify an appliance as being designed to correct a condition—here I quote from the amendment:wholly attributable to the condition known as presbyopia"—because spectacles of a given power may be used for reading or indeed any other purpose.
The only way consumers could know that such appliances were appropriate for them would be to know that they suffered from poor reading vision. That implies a sight test, which means that the amendment would be largely self-defeating. I am sure that that is not what the movers of the amendment have in mind.
Secondly, even if that can be cleared up, we should then be in difficulty with regard to children. The noble Lord, Lord Winstanley, in particular will know and approve of the modern trend towards identifying problems that children have with their health and bodily functions from a very young age indeed, even on occasion in utero. That early identification does not happen with eyes. But these days most children have eye tests at least from the age of five, and a growing number have them from the age of three. Otherwise if children have defective sight—for example, a squint—they will undergo severe learning difficulties when, for example, they are unable to read the blackboard at school.
The Government are proud of the activities of the primary care services in regard to children. Indeed, they have been praised this afternoon. The Government want to see those services continue and even expand. We conclude that this particular amendment would be a step backwards for children and should be amended specifically to exclude them.
There is a third, and I am sure unintentional, effect of the amendment. It is that it would prevent people from using the voucher scheme in full or partial payment of their fees for what the noble Lord, Lord Winstanley, called reading spectacles. A good 1262 amendment would continue the present arrangements for the remission of costs.
These are matters of detail. I appreciate that it is the principle that has engaged Members of the Committee this afternoon. But I should point out that if the principle were agreed today, the Government would need to bring their own amendments covering these points to amend the original amendment. It may perhaps be more proper to defer discussion of this until the next stage of the Bill. However, that is entirely up to the movers of the amendment, and is certainly not a matter for me.
§ Lord Ennals
I intentionally waited until after the Minister made his speech before making my contribution from these Benches. I totally disagree with the last conclusion that he reached. On the basis of the arguments which the Minister and a number of other Members of the Committee such as the noble Lords, Lord Cullen, Lord Trafford and Lord Hunter, have advanced, I think that the best thing is to defeat the amendment and not have to come back to it again. It seems to me a fairly offensive amendment and one which has some dangers to it.
It is said that the Chamber is always at its best when noble Lords are making personal reminiscences. In that case this must have been a great debate. But I do not think that it has been a great debate, because it has concentrated very much on the interests of those Members of the Committee who have supported the amendment and not very much on the interests of the other 12 million people who undergo eye tests.
As was said by the noble Lords, Lord Trafford and Lord Nugent, if this amendment were to be carried it would he a great disincentive to people to have eye tests at all. I was reading a letter that was received very recently from Ian Bruce of the Royal National Institute for the Blind. That body must know something about this problem. The letter stated that, if the amendment were carried, it would,decrease still further the number of people who have the benefit of an eye examination as part of a sight test, and will inevitably contribute to a rise in the number of people who lose their sight unnecessarily.That is a pretty powerful argument.
§ Lord Ennals
I notice that the noble Lord, Lord Orr-Ewing, said "No, no!" But the letter comes from the Royal National Institute for the Blind and I do not think that we can simply dismiss it out of hand. The British College of Optometrists, which has carried out a survey states:Twelve million 'sight-tests' or eye examinations are carried out each year in Great Britain under the NHS: in nearly a million of these cases, it is estimated that the patient is referred for medical investigation or his or her doctor is notified. If the results of the College's survey are applied to these figures, it will be seen that there may be up to a quarter of a million people each year who might experience no discomfort in using self selected reading spectacles, but who, if they bought such spectacles without first having had their eyes examined, would have put their vision or their general health at serious risk.Obviously some of those people who experience no discomfort in using self-selected reading spectacles 1263 are Members of the Committee. I submit that the British College of Optometrists also has some knowledge of this matter. I was a little worried that the Minister was not really giving a lead to the Chamber in this respect, because we discussed these matters very fully back in 1984. The Federation of Ophthalmic and Dispensing Opticians states:Since the beginning of 1985 it has been legal for unregistered traders to sell and supply spectacles to adults provided they comply with the Sale of Optical Appliances Order-in-Council 1984",and so on.
We decided in 1984 that any such sales:must be in accordance with a written prescription given by a doctor or registered ophthalmic optician following a sight test".I do not understand what has happened since 1984 to change the views of the Committee or of the Ministers who strongly commended that position the last time we debated the issue. Ministers repeatedly stated during the early stages of the Bill that it is not the Government's intention to:allow people to walk off the street into any shop that cares to display spectacles and to buy spectacles that have no relation to some measurement of what their eyes need".I agree with that. I wish that it had been said by the Minister in his brief comments this afternoon.
The legislation of ready-made spectacles would make a nonsense of the government amendment to the Bill, now incorporated in Clause 14(1). That proposes to give the Secretary of State the power to regulate what duties are to be performed in the course of a sight test by ophthalmic opticians and ophthalmic medical practitioners for the purpose of determining injury, disease or abnormalities of the eye. What would be the point of those provisions if a sight test could be avoided altogether by the purchase of ready-made spectacles?
By deciding that they will have a free vote and by not commending any action to the Committee, the Government have put themselves into an absurd position. Since 1945, numerous specs shops and unregistered traders have sprung up. Cases have been known of spectacles being sold from market stalls and even from barrows. The precise number of unregistered traders cannot be provided because it is inherent in the situation that there is no requirement for registration and no control by any regulatory body.
This is an issue on which, although the Government have not sought to impose the law, the General Optical Council has done so. As some of us will know, one of the major firms supplying those appliances in the UK is Magnivision. That firm has mounted a major campaign to change the law. I suppose that that is one of the reasons for the amendment which is before us today. It claims that there would be a significant price advantage for the consumer if sales were allowed. I do not believe that that is the case. Magnivision is currently the subject of several prosecutions being taken by the General Optical Council in respect of its sales of those items.
I believe that the noble Lord, Lord Cullen, quoted an official of Magnivision who said:We have recently increased our prices to £17.95 and £19.95. There is no way Magnivision would ever be able to profitably operate at lower retail prices".1264 The result of change in the law in this respect would therefore not produce any price advantage to the consumer but it would induce a significant health risk. No one has proved to us that there is a significant advantage in that for the consumer. It has been well proved to us by those who are experts—the noble Lord, Lord Hunter of Newington, is one of them—that there are dangers if people are discouraged from having sight tests.
I want the Minister to give a clear statement of the views of the Government to the Committee, based on the same evidence which led them earlier in the consideration of the Bill to come out clearly against what is contained in the amendment. Whether the Government care to do that or not, from this side of the Committee I strongly urge that the amendment be put to the vote and that we defeat it.
§ Lord Monson
Before the noble Lord, Lord Ennals, sits down, will he accept that those of us who support the amendment resent the insinuation that we are acting at the behest of Magnivision—a company of which I for one have never heard? Secondly, he asked how the position has changed since 1984. What has changed is the recent EC ruling which states that the provision of reading spectacles is not a medical matter.
§ Lord Ennals
I recognise that the noble Lord's second point has been mentioned during this 52-minute debate. I did not intend to suggest that those who moved the amendment were doing so as a result of a campaign run by Magnivision. However, the noble Lord can hardly have been following what has been going on in the field of medicine or comfort or whatever he may call it if he is unaware of the Magnivision story, which has gained tremendous publicity. I do not suggest for a moment that any Member of the Committee has been influenced by that commercial enterprise.
§ Viscount Montgomery of Alamein
The noble Lord, Lord Ennals, said that several noble Lords had spoken from personal experience and without regard to the consumer. I disagree with him. Having listened to the noble Lord and his supporters, it seems to me that they have the consumer in mind.
The purpose of the amendment is to allow magnifying spectacles to be made available across the counter. It may well be that they will be available in supermarkets, on barrows and suchlike places of which the noble Lord disapproves. However, if glasses of that sort cause no damage to the eyes—the noble Lord, Lord Winstanley, has indicated that that is the case—it seems to me to be wholly desirable in the interest of consumers that they should be more widely available. I hope that the noble Lord, Lord Winstanley, will press the amendment.
A noble Lord who tables an amendment to a Bill is wholly responsible for the wording of it. I have been reliably informed that the wording of the amendment is defective. I therefore accept that the fault is clearly mine. However, I hope that the Committee will accept that I did my best. I first tabled a simple amendment which merely 1265 prescribed that a pair of spectacles containing a pair of identical magnifying lenses should be exempt. I was informed that that did not wholly meet my intention. I was advised by someone in the department, who did not come down on one side or the other of the argument, that the present amendment was a better way of achieving my objective. Apparently that was wrong. I shall have to make inquiries about whether I should revert to the old wording.
I do not feel that there would be great benefit in pressing the Committee to divide on an amendment which is defective. I shall have to think carefully about whether I shall table the amendment again. One consideration is that if I tabled the amendment in another form, I should have to listen to the speech of the noble Lord, Lord Ennals, again. I should not wish to bring that down upon myself. I should also have to consider carefully some of the arguments advanced.
I was astonished at the arguments advanced by the noble Lord, Lord Trafford. I have great respect for his clinical judgment. He is a consultant physician and ranks higher than I do in the medical profession. I have always believed that consultants should spend a certain amount of time in general practice. No doubt the noble Lord will say that he has done so. However, I am sure that if he were to spend time in general practice he would agree with me that if he, as a general practitioner, suspected one of his elderly patients might conceivably have incipient glaucoma, he would not send that patient to an optician. He would send his patient to an eye hospital or to a consultant ophthalmologist.
The previous arrangements with regard to eye testing were not the great safety net which some noble Lords have portrayed. I believe that people who think that are misleading themselves. There are reasons for considering the amendment further. This is not the right time to put the matter to a vote. I shall consider the matter and new wording further. I beg leave to withdraw the amendment.
§ Lord Ennals
I believe that the noble Lord requires the permission of the Committee to withdraw the amendment. I wish to oppose the withdrawal of the amendment.
§ The Deputy Chairman of Committee (Earl Cathcart)
Is it your Lordships pleasure that this amendment be withdrawn?
§ The Deputy Chairman of Committees
The Question is that Amendment No. 48 be agreed to. As many as are of that opinion will say "Content"; to the contrary, "Not-Content". I think the Not-Contents have it. Clear the Bar.
§ 6.49 p.m.
§ On Question, Whether the said amendment (No. 48) shall be agreed to?
§ Their Lordships divided: Contents, 84; Not-Contents, 80.1267
|Arran, E.||Hunt, L.|
|Ashbourne, L.||Joseph, L.|
|Balfour, E.||Kilbracken, L.|
|Boardman, L.||Kimball, L.|
|Bonham-Carter, L.||Lindsey and Abingdon, E.|
|Borthwick, L.||Long, V.|
|Bottomley, L.||Luke, L.|
|Boyd-Carpenter, L.||Mackay of Clashfern, L.|
|Brabazon of Tara, L.||Mar, C.|
|Bruce-Gardyne, L. [Teller.]||Mersey, V.|
|Buckinghamshire, E.||Monk Bretton, L.|
|Burton, L.||Monson, L.|
|Caithness, E.||Montgomery of Alamein, V.|
|Cameron of Lochbroom, L.||Mountevans, L.|
|Carnock, L.||Norfolk, D.|
|Clitheroe, L.||Orr-Ewing, L.|
|Colwyn, L.||Oxfuird, V.|
|Constantine of Stanmore, L.||Peston, L.|
|Davies of Penrhys, L.||Polwarth, L.|
|Dilhorne, V.||Rankeillour, L.|
|Donegall, M.||Renton, L.|
|Dundee, E.||Rugby, L.|
|Elibank, L.||St. John of Bletso, L.|
|Elliott of Morpeth, L.||Saltoun of Abernethy, Ly.|
|Erroll, E.||Sanderson of Bowden, L.|
|Fanshawe of Richmond, L.||Savile, L.|
|Ferrers, E.||Skelmersdale, L.|
|Gardner of Parkes, B.||Stodart of Leaston, L.|
|Gray of Contin, L.||Strathclyde, L.|
|Greenway, L.||Strathcona and Mount Royal, L.|
|Hailsham of Saint Marylebone, L.|
|Halsbury, E.||Taylor of Blackburn, L.|
|Hanson, L.||Taylor of Gryfe, L. [Teller.]|
|Hardinge of Penshurst, L.||Thurlow, L.|
|Harmar-Nicholls, L.||Torphichen, L.|
|Harris of Greenwich, L.||Trumpington, B.|
|Harvington, L.||Whitelaw, V.|
|Henderson of Brompton, L.||Willis, L.|
|Hesketh, L.||Windlesham, L.|
|Holderness, L.||Winstanley, L.|
|Hooper, B.||Young of Graftham, L.|
|Hooson, L.||Zouche of Haryngworth, L.|
|Ardwick, L.||Hughes, L.|
|Auckland, L.||Hunter of Newington, L.|
|Bauer, L.||Hylton-Foster, B.|
|Birdwood, L.||Jay, L.|
|Blackstone, B.||Jeger, B.|
|Blease, L.||Johnston of Rockport, L.|
|Brain, L.||Kinnoull, E.|
|Brookeborough, V.||Kirkhill, L.|
|Brooks of Tremorfa, L.||Lawrence, L.|
|Brougham and Vaux, L.||Layton, L.|
|Carmichael of Kelvingrove, L.||Longford, E.|
|Carter, L. [Teller.]||Lucas of Chilworth, L.|
|Cathcart, E.||McFadzean, L.|
|Cledwyn of Penrhos, L.||Macleod of Borve, B.|
|Cullen of Ashbourne, L.||Marley, L.|
|Darcy (de Knayth), B.||Marshall of Leeds, L.|
|Dormand of Easington, L.||Masham of Ilton, B.|
|Dormer, L.||Mason of Barnsley, L.|
|Elliot of Harwood, B.||Merrivale, L.|
|Elwyn-Jones, L.||Milner of Leeds, L.|
|Ennals, L.||Milverton, L.|
|Faithfull, B.||Morton of Shuna, L.|
|Gallacher, L.||Mulley, L.|
|Galpern, L.||Napier and Ettrick, L.|
|Graham of Edmonton, L.||Nelson, E.|
|Gregson, L.||Nicol, B.|
|Grimston of Westbury, L.||Northesk, E.|
|Headfort, M.||Nugent of Guildford, L.|
|Hives, L.||Orkney, E.|
|Home of the Hirsel, L.||Parry, L.|
|Houghton of Sowerby, L.||Ponsonby of Shulbrede, L. [Teller.]|
|Howie of Troon, L.|
|Prys-Davies, L.||Taylor of Mansfield, L.|
|Rea, L.||Thomas of Gwydir, L.|
|Rochdale, V.||Tonypandy, V.|
|Rodney, L.||Trafford, L.|
|Seebohm, L.||Underhill, L.|
|Serota, B.||Wallace of Coslany, L.|
|Stedman, B.||Wells-Pestell, L.|
|Stoddart of Swindon, L.||White, B.|
§ Resolved in the affirmative, and amendment agreed to accordingly.
§ 7 p.m.
§ On Question, Whether Clause 13, as amended, shall stand part of the Bill?
§ Lord Skelmersdale
Perhaps I may say a very brief word. Although clearly we have lost the meat of the clause it contains other important features. It will enable us to extend the spectacle voucher scheme; it will enable us to make payments for the cost of repairing or replacing spectacles for children and the handicapped. I am sure that the Committee will consider that a welcome extension of the scheme. For that reason I should like to see the clause remain part of the Bill.
I understand that my noble friend Lord Bruce-Gardyne wishes to put a question to me on the clause.
§ Lord Bruce-Gardyne
I wish to intervene in regard to matters that my noble friend has just mentioned—other provisions of the clause that we have not discussed at any length—with special reference to Clause 13(3). I am concerned about a related matter, of which I have given my noble friend warning. It is a narrow point but one that I believe will be of considerable concern to a small number of people. I hasten to say that it is not entirely germane to the clause. I shall therefore be brief. It concerns another category of appliance that the health service may supply—commercial hearing aids for the small number of people who are unable to benefit from NHS hearing aids. My interest in the matter arises from the fact that I have a son who has always been in precisely that position.
Because of a recent decision of the European Court, it has been decided that VAT must apply to commercial hearing aids in a way that it has not hitherto. The anxiety arises because, under the provisions of the clause, the health service has an obligation to supply a commercial hearing aid where a specialist or consultant says that the patient needs one and cannot benefit from an NHS appliance. Because of financial pressure, local health authorities have already been finding it very difficult to fulfil that requirement. The addition of VAT to the cost of commercial hearing aids will obviously add to those financial pressures and will increase the difficulties of a small number of people who are genuinely dependent on the health service for access to hearing aids.
At this stage I ask my noble friend to look into the matter sympathetically and see whether something can be done—I ask for no undertaking now—to alleviate what is a narrow but serious problem for a small number of people.
§ Lord Skelmersdale
My noble friend gave me a few days' warning of his question, and I have been able to look into it.
I understand that the European Court judgment is binding on the United Kingdom and there is no room for manoeuvre over its application to hearing aids. Because the subject under discussion is value added tax and not specifically medical aids, this would therefore be a matter for the Finance Bill and Treasury Ministers.
I should make clear that the exemption against which the court has ruled covered only the sale of hearing aids to users by hearing aid dispensers; it did not cover purchases by the NHS from suppliers, who already pay VAT. The court ruling will not therefore increase prices to health authorities, which I understood to be my noble friend's major point. Health authorities provide hearing aids to patients on free loan, so that neither the health authorities nor the patients will be affected by this imposition of value added tax.
§ Clause 13, as amended, agreed to.
§ Clause 14 [Sight-testing]:
Lord Cullen of Ashbourne moved Amendment No. 49:
Page 18, line 11, leave out from ("require") to end of line 18.
§ The noble Lord said: Clause 14 in general terms is designed to give the Secretary of State power to lay down in regulations exactly what the duties of an OMP or ophthalmic optician are when carrying out a sight test.
§ I am president of the Federation of Ophthalmic and Dispensing Opticians—FODO—which does not object to the general proposition that it may be desirable to prescribe minimum standards for the content of an eye examination, although it seems something of an interference with private contracts to do so in the case of private eye examinations. The provision that we find objectionable is paragraph (b) of subsection (1), which requires the prescriber to give all patients following a sight test a written statement, first, that he has carried out the examinations that the regulations require; and, secondly, that he is or, as the case may be, is not referring him to a registered medical practitioner. We do not understand the reasons for including in the clause a duty to hand to patients a written statement that the practitioner has carried out the required examination in accordance with the regulations.
§ Ophthalmic medical practitioners and ophthalmic opticians are already liable in negligence at common law if they fail in their duties when carrying out an eye examination. We do not see that the statutory obligation to perform certain duties is strengthened in any way by including a statutory requirement to give all patients a written statement that the examination has been conducted.
§ There seems no real reason to doubt that whatever is specified in the regulations will be carried out. The requirement to certify their completion in this clause seems very heavyhanded and bureaucratic. Patients 1269 are already entitled to be given their prescription and, in effect, the prescription should itself be the evidence that they have been given a proper eye examination by the practitioner concerned. I beg to move.
§ Lord Ennals
I need say no more than a few sentences as the noble Lord, Lord Cullen of Ashbourne, has set out the matter clearly.
Like the noble Lord, I do not know why the Government decided to include this bureaucratic regulation in the Bill. Whether it implies some lack of confidence in the practitioners concerned I do not know. I hope that the Minister will think again and decide that this is an unnecessary and time-wasting provision. I shall be interested to hear what he says.
§ Lord Skelmersdale
I assure the Committee that there is no ulterior motive here. The requirements that the amendment seeks to remove are not intended in any way as a slight to the profession; they are simply part of our measures to help the consumer. I do not think it unreasonable that patients should be given written confirmation that the practitioner has carried out the eye examination required by regulation.
The noble Lord, Lord Winstanley, earlier praised the regulations, which for the first time will make a form of eye test prescribable under Clause 14. The written confirmation will be useful should any dispute arise over the sight test. A statement of the practitioner's advice where the patient is being referred to the doctor will serve as a useful reminder.
I do not think that these requirements will be onerous for the practitioners as, along with details of the prescription or statement that spectacles are not required, they could be included on a single piece of paper. This provision would have taken on very much more significance in the light of the proposal for a large increase in the number of private sight tests. But it is of importance even when that proposal has not met the wishes of Members of the Committee. It is an important consumer protection measure.
I must confess that these are my preliminary thoughts on the issue. If my noble friend would like to have consultations with me, involving perhaps talks between his advisers and my advisers before the next stage of the Bill, I should be very happy to agree to that.
§ Lord Ennals
The Minister made the point that when this was put into the Bill in another place it was on the assumption that there would be sight tests that would be paid for—therefore private sight tests. That has now been deleted. Is there not an argument for his thinking again as he suggests?
§ Lord Skelmersdale
Clearly this is one of the considerations between now and the next stage of the Bill. However, as I said earlier, it is not the only consideration.
§ Lord Cullen of Ashbourne
It is obvious that we all have to think again about this. I am grateful to my noble friend for offering consultation between now 1270 and Report stage. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Clause 14 agreed to.
§ Clause 15 agreed to.
§ Clause 16 [Limits on reimbursement of expenses]:
Lord Ennals moved Amendment No. 50:
Page 20, line 3, at end insert—
("and, (iv) for the purposes of (ii) above, the expenditure attributable to reimbursement of expenses shall relate only to expenditure attributable to the reimbursement of expenses made in respect of the Cost Rent Scheme and the Direct Payments for Ancillary Staff Scheme (provided for in accordance with Regulation 24 of the National Health Service (General Medical and Pharmaceutical Service) Regulations 1974, as amended.)").
§ The noble Lord said: The purpose of this amendment is to ensure that cash limits affect expenditure only on the cost rent scheme and payments for ancillary staff.
§ I made clear at Second Reading that I have no objection in principle to cash limiting. If I had objected the Minister would have been at my throat, my having played a role in cash limits at an earlier stage in my life. I said on Second Reading that Clause 16 concerning reimbursement of expenses provides for a cash-limited grant to family practitioner committees from the DHSS to reimburse those family practitioner services of various expenses—providing principally, I presume, for taking on additional staff within GP practices, as was suggested in the White Paper. One would welcome that. I do not object to it. That is the position I take now.
§ However, I wish to make certain that cash limiting is not extended to other aspects of the general practitioner's work. I believe very much in the clinical judgment of a general practitioner. I do not wish to see cash limiting affecting his clinical judgment and the practices that he furthers as a result of using that clinical judgment. Nor do I wish it to affect the cost of the prescribing that he undertakes.
§ I wish the Minister to tell me that the cash limiting applies only in the two particular respects I have mentioned. If he does not say that, of course 1 shall wish the amendment to be passed in order to make it clear. If he is able to give me an absolutely clear assurance, then it will not be my intention to push the amendment to a Division.
§ Lord Skelmersdale
The cash-limiting provisions—the noble Lord was good enough to say he was not against them in principle—that we seek in this clause have very positive advantages in targeting resources where they are most needed to improve patient care. The clause will enable the Government first to remove a number of central constraints on the greater use of practice team staff and, second, to improve surgery premises. However, the source of funds is, as usual, not a bottomless purse. The greater local flexibility we are aiming to create must be balanced by a central mechanism for controlling the expenditure. Otherwise, one practice might well be very highly staffed whereas another practice, not 1271 many miles down the road, could have many fewer staff. That would be inappropriate. In other words, we wish to keep a balance. We wish to keep a measure of control.
Having said that, we believe that it is right to maximise local decision-making with the minimum degree of central control. The cash limiting provisions will achieve this. However, we know that there is concern about how the provisions will be used. The noble Lord, Lord Ennals, referred rather obliquely to that concern.
The Government have already made clear—and I repeat again—that they have no plans to use the cash-limiting powers other than in respect of GPs' premises improvements and practice team staff. Nevertheless, for the reasons that I have already given, we believe that cash limits will be of considerable value in ensuring the effective targeting of resources in these two important areas of service development.
I think that I have given the reassurances that the noble Lord was seeking. If not, I have no doubt that he will come back to me.
§ Lord Ennals
I am grateful to the Minister for what he said. Having a suspicious mind, I always cavil a little at statements like, "I have no plans". Sometimes, three months later, someone then has plans. I remember at the time of an election a few years ago, the Prime Minister said that she had no intention to increase prescription charges. At that moment she had not; but as soon as she became Prime Minister she jolly well did and we have suffered from them ever since.
I wish to read carefully what the Minister has said and to consider whether I ought to raise the matter at a later stage. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendments Nos. 51 and 52 not moved.]
§ Clause 16 agreed to.
§ 7.15 p.m.
§ Clause 17 [Transfer of staff from civil service to health authorities]:
The Earl of Arran moved Amendments Nos. 53 and 54:
Page 20, line 26, leave out from second ("a") to ("on") in line 28 and insert ("body constituted under the National Health Service Act 1977 or the National Health Service (Scotland) Act 1978 or section 91(2) of the Mental Health (Scotland) Act 1984").
Page 20, line 32, leave out ("health authority") and insert ("body whose employee he becomes")
§ The noble Earl said: Before turning to these two small amendments to Clause 17, I should like to pay tribute to my noble friend Lord Holderness who has been chairman of the Disablement Services Authority since July 1987. In that capacity he has been extremely active in promoting the work of the DSA. His chairmanship has been most valuable and he has been supportive of the proposed changes put forward in the clause.1272
§ These amendments are of a tidying-up nature. They are designed to extend the employment protection offered by the clause to transfer to any body constituted under the National Health Service Act 1977, the National Health Service (Scotland) Act 1978 or Section 91(2) of the Mental Health (Scotland) Act 1984—not just health authorities, as currently drafted. I beg to move.
§ On Question, amendments agreed to.
§ Clause 17, as amended, agreed to.
§ Clause 18 agreed to.
§ Clause 19 [Instruction of staff in matters relating to health and welfare]:
The Earl of Arran moved Amendment No. 55:
Page 20, line 44, leave out from ("63") to ("in") in line 45 and insert ("of the Health Services and Public Health Act 1968—
§ The noble Earl said: Clause 19 extends our powers to make grants to local authorities for the training of social services staff. We attach great importance to training as a means of improving the quality of services which are provided. It is also important for improving the effectiveness with which the resources—human and financial—which we devote to social services are used. This year we have launched the training support programme directed at certain groups of social services staff working with the elderly. The programme has been enthusiastically received by local authorities and welcomed by noble Lords. All 109 personal social service authorities have submitted a successful bid for a grant under the programme.
§ Many training sessions are now under way. The powers we are taking under this clause will allow us to extend the programme to other priority areas of social services. For example, my right honourable friend the Minister for Health announced as part of his response to the Butler-Sloss report that, subject to the passage of the Bill, we shall be launching a training support programme for child care staff.
§ The amendment is needed because the clause as drafted would not allow the funding of administrative staff—for example, the student placement officers—which is an important part of the initiative proposed for the training of child care staff. I beg to move.
§ On Question, amendment agreed to.
§ Clause 19, as amended, agreed to.
§ Clause 20 agreed to.
Lord Ennals moved Amendment No. 56:
After Clause 20, insert the following new clause:
§ ("Prescription by nurses.
- "(i) to the sale or supply of all medicinal products that are not prescription-only medicines, where the product is sold or supplied by a registered nurse of a category specified in an order made by the Health Ministers for the purposes of this paragraph in the course of her professional practice;
- (ii) and to the sale or supply of prescription-only medicines which, by virtue of an exemption conferred by an order made under section 58(4)(a), may be sold or supplied by a registered nurse of a category specified in an order made by the Health Ministers for the purposes of this paragraph, otherwise than in accordance with a prescription given by an appropriate practitioner; or".").
§ The noble Lord said: At present, nurses have no power to prescribe even the simplest drugs and appliances, including simple painkillers which can be bought over the pharmacist's counter. Frequently district nurses and other nursing staff working in the community waste considerable time obtaining items such as new dressings for their patients. They must first obtain a prescription from the doctor, who may never even have seen the patient. They then have to obtain the item from the pharmacist and take it back to the patient. Delays in treatment and inconvenience to patients can thus occur and nursing time and travel costs be wasted.
§ In many cases the community nurse is in reality the prescriber and the GP merely the authoriser. There has been fairly wide agreement that there would be much merit in introducing nurse prescribing in certain situations. It could be said that some groups of nurses, including occupational health nurses, midwives and some nurses in the armed forces, already possess these powers. Nurses with special training have in recent years been assuming responsibilities for various dosages and amending treatment within carefully controlled protocols agreed with doctors. Indeed, in many instances patients themselves are tending to be self-prescribers with medicines provided to them as over-the-counter preparations. It is not unreasonable to suggest that nurses are at least as competent as patients (and, some might think, as doctors) in the areas we are talking about.
§ This has been accepted in principle and it was my feeling that it ought to be enshrined within the Bill. Though this is not an amendment that I have any intention of pressing to a vote—it is in part a probing amendment—there are a few questions I should like to put to the Minister. I know that a committee has been established to discuss this matter with the professions, including the Royal College of Nursing. I should like to know what stage these consultations have reached. What is the remit of the committee? In other words, is it considering the principle of nurse prescribing or the details? What work has the committee carried out to date? What is the timetable for the committee's future work? When does it expect to complete its work? Who are its members? These are all questions the answers to which I should find very interesting, as I am sure would other members of the Committee. I know that the Royal College of Nursing and other organisations involved with nurses would very much like to know what progress is being made. I beg to move.
§ Lord Trafford
It is somewhat of a pleasure for me to be able to support an amendment moved by the noble Lord. Whether it has exactly the correct wording I am not sure, but I support the principle of nurse prescribing, certainly for the simpler preparations. It has not perhaps escaped the attention of some noble Lords who attend health 1274 debates that I am a very strong supporter of the role of nurses. They are absolutely critical in the health service and I support this movement in principle though, as I have said, I do not know whether the wording is entirely correct.
To allow nurses to play a bigger part in their delivery of health care is important. As some of your Lordships may know, it is my duty in another field to run a renal dialysis and transplant unit. The nurses are specially and highly trained. It would be utterly ludicrous if one expected many doctors to know as much about the activities that these nurses carry out as they do in another field in which I operate; the intensive care unit. I therefore strongly support the idea that nurses can be most useful.
There is plenty of scope for prescription. Nurses can do an enormous amount to contribute materially to the patients. I do not believe that they necessarily need to have imposed upon them the ludicrous restrictions that now apply. Nurses very frequently are not able to prescribe the most simple of remedies and are not able to obtain items such as dressings, ointments and so on to treat, for example, the varicose ulcers with which they deal very frequently in general practice. I make that point because of the comment made on my experience in general practice by the noble Lord, Lord Winstanley. I point out to him that I also did some general practice in my time. This is an extremely useful measure.
Even in the field of hospital service, where nurses are more closely supervised, the same would apply, because they are in more immediate contact, and I support such manoeuvres. I do not wish to detain the Committee, but it may interest Members to know that frequently in these more specialised procedures the nurse knows as much or more than the attending junior doctor before he has been fully trained. It is always amusing to see the way in which the nurse or the sister carefully instructs the junior doctor in what will be the best steps to take with regard perhaps to the dialysis machine or the respirator or how to use the defibrillator or whatever the instrument may be. I remain deeply impressed by the capacity of nurses, given their head, though perhaps not all that freely in the sense that there must be some degree of control in such a situation. I support the general principle behind the amendment.
As has been apparent, I have not been in total agreement with the noble Lord, Lord Ennals, throughout the whole of the proceedings in the Committee today. Therefore it gives me great pleasure to say that I support him entirely on that amendment. The point that the noble Lord, Lord Trafford, made is valid. He mentioned varicose ulcers. When I was in general practice with a patient with a varicose ulcer at home, he or she was looked after in the main by the community nurse, as she is now called. The nurse would dress the ulcer with whatever it needed to be dressed with and would constantly make changes. She would always have to come to me to ask for a prescription for this, that or the other. She would tell me what she wanted the prescription for and, having given her the prescription, she would have it made up for the patient. Then she would apply the different items to 1275 the patient. It was an absurd situation. There cannot be any argument against a procedure such as this, limited though it is. I hope that the Minister will tell us that the Government intend to follow this route, whether by this means or another, I know not.
§ Lord Rea
The noble Lord, Lord Winstanley, says that it was an absurd situation for the nurse to tell him what she wanted so that he could write out the prescription. It still is an absurdity. It is still happening. The amendment would be much welcomed by many workers in primary health care as well as in hospital. I fully support it.
§ The Countess of Mar
I should like to support the amendment. For a number of years I worked in a busy casualty department of a Scottish hospital attended by a GP; there was no permanent doctor. The sister and staff nurse frequently decided on—rather than prescribed—the treatment to give to a patient. The amendment would bring community nurses on to a level with sisters in the same kind of situation.
§ 7.30 p.m.
§ The Earl of Arran
We are glad that there is a certain amount of unanimity in the air this evening, particularly from all sides of the Committee. I believe that I shall be able to help the noble Lord, Lord Ennals, in respect of some of the points that he raised.
We made it clear when we issued the primary health care White Paper and since then we have been in favour of giving nurses more freedom to prescribe a limited range of items and to exercise their professional judgment in relation to the timing and dosage of certain drugs prescribed by doctors. It is hard to detect among the many supporters of the idea—Members of the Committee not excepted—any general agreement about what nurses should be able to prescribe and in what circumstances. These and other related matters need careful thought. We believe that the amendment, which would pre-empt any decision on them in respect of non-prescription only products, goes too far at this stage.
Following an initial approach to the professional standing advisory committees we have now set up a joint working party to examine the professional and ethical issues of nurse prescribing. I am happy to be able to tell the Committee and the noble Lord, Lord Ennals, that the working party meets for the first time today. I believe that as yet it is a little too early to say when the work will finish.
It is also too early to say precisely what products nurses should be allowed to supply or what legislative measures might be needed in consequence. As regards provisions of the Medicines Act, we are advised that there are sufficient powers at present in the Act to enable any necessary changes to be made by subordinate legislation.
I hope that, in view of the reassurances I have given to the Committee and in particular to the noble Lord, Lord Ennals, he will feel able to withdraw the amendment.
§ Lord Ennals
I should like to thank the noble Earl for his constructive reply. I should also like to thank the three doctors who fully supported the principle underlying my amendment. It was most encouraging and I know that members of the nursing profession will also find it so. I indicated that it was not my intention to press the matter to a Division.
I am glad that the working party met today. I do not know whether the fact that I had tabled an amendment speeded up the date of the meeting. I was a little worried about when the meeting would take place and I am happy that the committee has met today.
Perhaps the Minister can say something about the possibility of regulations being introduced under existing primary legislation as a result of the work of the working party enabling nurses in certain fields to prescribe. I do not know which Act applies and I had not realised that such a power could be introduced without primary legislation. If the Minister does not have the answer I do not wish to press him but perhaps he will write to me. I asked a number of other questions concerning the composition and terms of reference of the working party and I should like to have that information together with the possibility of regulations. If the Minister can answer my questions now, it will save half the letter that I hope he will write to me. I shall listen to his answer and then indicate my intention.
§ The Earl of Arran
I believe that it would be achieved by regulations under the Medicines Act 1968. The noble Lord asked about the composition of the committee. It is chaired by Dr. June Crown, director of service evaluation development of the Bloomsbury Health Authority, and four other people.
§ Lord Ennals
I thank the noble Earl. Under those circumstances I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Clauses 21 and 22 agreed to.
§ Clause 23 [Commencement and transitional]:
The Earl of Arran moved Amendment No. 57:
Page 23, leave out line 27 and insert ("section 1 (including Schedule [Provisions supplementary to s.1] (and sections 2 to 6;").
§ The noble Earl said: The amendment has already been spoken to. I beg to move.
§ On Question, amendment agreed to.
§ Clause 23, as amended, agreed to.
§ Clause 24 [Northern Ireland]:
The Earl of Arran moved Amendment No. 58:
Page 24, line 22, leave out first ("section") and insert ("sections 14 and").
§ The noble Earl said: On behalf of my noble friend, I beg to move Amendment No. 58. It is a technical amendment correcting an accidental omission from Clause 24. It ensures that Clause 14, an amendment 1277 to the Opticians Act, which is a United Kingdom Act, is commenced in Northern Ireland as well as in Great Britain.
§ On Question, amendment agreed to.
§ Clause 24, as amended, agreed to.
§ Clause 25 agreed to.
The Earl of Arran moved Amendment No. 59:
Before Schedule 1, insert the following new schedule: